Methods and systems for treating a chronic low back pain condition using an implantable electroacupuncture device

ABSTRACT

An exemplary method of treating a chronic low back pain condition in a patient includes 1) generating, by an electroacupuncture device implanted beneath a skin surface of the patient at at least one of acupoints BL22, BL23, BL24, BL25, and BL26 within the patient, stimulation sessions at a duty cycle that is less than 0.05, wherein the duty cycle is a ratio of T 3  to T 4  and each stimulation session included in the stimulation sessions has a duration of T 3  minutes and occurs at a rate of once every T 4  minutes, and 2) applying, by the electroacupuncture device, the stimulation sessions to the target tissue location in accordance with the duty cycle.

RELATED APPLICATIONS

The present application is a continuation-in-part application of U.S.application Ser. No. 13/796,314(now U.S. Pat. No. 9,327,134), filed Mar.12, 2013, and claims priority under 35 U.S.C. §119(e) to U.S.Provisional Patent Application No. 62/030,589, filed Jul. 29, 2014, andU.S. Provisional Patent Application No. 62/091,333, filed Dec. 12, 2014.U.S. application Ser. No. 13/796,314 is a continuation-in-partapplication of U.S. application Ser. No. 13/598,582(now U.S. Pat. No.8,965,511), filed Aug. 29, 2012; U.S. patent application Ser. No.13/622,653(now U.S. Pat. No. 8,996,125), filed Sep. 19, 2012; and U.S.patent application Ser. No. 13/630,522(now U.S. Pat. No. 9,173,811),filed Sep. 28, 2012. U.S. application Ser. No. 13/796,314 also claimspriority under 35 U.S.C. §119(e) to U.S. Provisional Patent ApplicationNo. 61/609,875, filed Mar. 12, 2012; U.S. Provisional Patent ApplicationNo. 61/672,257, filed Jul. 16, 2012; U.S. Provisional Patent ApplicationNo. 61/672,661, filed Jul. 17, 2012; U.S. Provisional Patent ApplicationNo. 61/673,254, filed Jul. 19, 2012; U.S. Provisional Patent ApplicationNo. 61/674,691, filed Jul. 23, 2012; and U.S. Provisional PatentApplication No. 61/676,275, filed Jul. 26, 2012. All of theseapplications are incorporated herein by reference in their respectiveentireties.

BACKGROUND INFORMATION

Low back pain is a major health problem that causes high medicalexpenses, absenteeism in the workplace and disablement. Low back pain ischaracterized as chronic when it persists for at least three months;otherwise, it is called “acute.”

There are three patterns of back pain: axial, referred, and radicular.Axial pain is that localized to the back, which usually gets better withpain medication and physical therapy. Referred pain is an achy, dullpain that extends from the back to the extremities along the nerve path.Referred pain may come and go, move around in location, and vary inintensity. Radicular pain is a deep, steady pain that radiates from theback to the extremities and is associated with certain activities likestanding, walking, or sitting. Sciatica is an example of the most commonversion of radicular pain.

Four out of five adults experience significant low back pain at somepoint in their lives. The major causes of back pain in adults are:sprains, strains, and spasms; degenerative changes of the spinal bonesand disks; herniated disks; vertebral compression fractures; spinalstenosis; and spinal deformities. Additionally, sciatica and caudaequina syndrome are two conditions caused by spinal stenosis or diskherniation.

An alternative approach for treating chronic low back pain, diabetes,high cholesterol and a host of other physiological conditions,illnesses, deficiencies and disorders is acupuncture, which includestraditional acupuncture and acupressure. Acupuncture has been practicedin Eastern civilizations (principally in China, but also in other Asiancountries) for at least 2500 years. It is still practiced todaythroughout many parts of the world, including the United States andEurope. A good summary of the history of acupuncture, and its potentialapplications may be found in Cheung, et al., “The Mechanism ofAcupuncture Therapy and Clinical Case Studies”, (Taylor & Francis,publisher) 2001) ISBN 0-415-27254-8, hereafter referred to as “Cheung,Mechanism of Acupuncture, 2001.” The Forward, as well as Chapters 1-3,5, 7, 8, 12 and 13 of Cheung, Mechanism of Acupuncture, 2001, areincorporated herein by reference.

Despite the practice in Eastern countries for over 2500 years, it wasnot until President Richard Nixon visited China (in 1972) thatacupuncture began to be accepted in the West, such as the United Statesand Europe. One of the reporters who accompanied Nixon during his visitto China, James Reston, from the New York Times, received acupuncture inChina for post-operative pain after undergoing an emergency appendectomyunder standard anesthesia. Reston experienced pain relief from theacupuncture and wrote about it in The New York Times. In 1973 theAmerican Internal Revenue Service allowed acupuncture to be deducted asa medical expense. Following Nixon's visit to China, and as immigrantsbegan flowing from China to Western countries, the demand foracupuncture increased steadily. Today, acupuncture therapy is viewed bymany as a viable alternative form of medical treatment, alongsideWestern therapies. Moreover, acupuncture treatment is now covered, atleast in part, by most insurance carriers. Further, payment foracupuncture services consumes a not insignificant portion of healthcareexpenditures in the U.S. and Europe. See, generally, Cheung, Mechanismof Acupuncture, 2001, vii.

Acupuncture is an alternative medicine that treats patients by insertionand manipulation of needles in the body at selected points. See, Novak,Patricia D. et al (1995). Dorland's Pocket Medical Dictionary (25thed.), Philadelphia: (W.B. Saunders Publisher), ISBN 0-7216-5738-9. Thelocations where the acupuncture needles are inserted are referred toherein as “acupuncture points” or simply just “acupoints”. The locationof acupoints in the human body has been developed over thousands ofyears of acupuncture practice, and maps showing the location ofacupoints in the human body are readily available in acupuncture booksor online. For example, see, “Acupuncture Points Map,” found online at:http://www.acupuncturehealing.org/acupuncture-points-map.html. Acupointsare typically identified by various letter/number combinations, e.g.,L6, S37. The maps that show the location of the acupoints may alsoidentify what condition, illness or deficiency the particular acupointaffects when manipulation of needles inserted at the acupoint isundertaken.

References to the acupoints in the literature are not always consistentwith respect to the format of the letter/number combination. Someacupoints are identified by a name only, e.g., Shenshu. The sameacupoint may be identified by others by the name followed with aletter/number combination placed in parenthesis, e.g., Shenshu (BL23).Alternatively, the acupoint may be identified by its letter/numbercombination followed by its name, e.g., BL23 (Shenshu). The first lettertypically refers to a body organ, or meridian, or other tissue locationassociated with, or affected by, that acupoint. However, usually onlythe letter is used in referring to the acupoint, but not always. Thus,for example, the acupoint BL23 is the same as acupoint Bladder 23 whichis the same as BL-23 which is the same as BL 23 which is the same asShenshu. For purposes of this patent application, unless specificallystated otherwise, all references to acupoints that use the same name, orthe same first letter and the same number, and regardless of slightdifferences in second letters and formatting, are intended to refer tothe same acupoint.

An excellent reference book that identifies all of the traditionalacupoints within the human body is WHO STANDARD ACUPUNCTURE POINTLOCATIONS IN THE WESTERN PACIFIC REGION, published by the World HealthOrganization (WHO), Western Pacific Region, 2008 (updated and reprinted2009), ISBN 978 92 9061 248 7 (hereafter “WHO Standard Acupuncture PointLocations 2008”). The Table of Contents, Forward (page v-vi) and GeneralGuidelines for Acupuncture Point Locations (pages 1-21), as well aspages 110-112 (which illustrate with particularity the location ofacupoints BL22, BL23, BL24, BL25, BL26) of the WHO Standard AcupuncturePoint Locations 2008 are incorporated herein by reference. The relevantinformation from pages 110-112 of the WHO Standard Acupuncture PointLocations 2008 book is also presented herein as FIG. 1A, andaccompanying text.

It should be noted that other medical research, not associated withacupuncture research, has over the years identified nerves and otherlocations throughout a patient's body where the application ofelectrical stimulation produces a beneficial effect for the patient.Indeed, the entire field of neurostimulation deals with identifyinglocations in the body where electrical stimulation can be applied inorder to provide a therapeutic effect for a patient. For purposes ofthis patent application, such known locations within the body aretreated essentially the same as acupoints—they provide a “target”location where electrical stimulation may be applied to achieve abeneficial result, whether that beneficial result is to treat back pain,reduce cholesterol or triglyceride levels, to treat cardiovasculardisease, to treat mental illness, or to address some other issueassociated with a disease or condition of the patient.

Some have proposed applying moderate electrical stimulation at selectedacupuncture points through needles that have been inserted at thosepoints. See, e.g., http://en.wikipedia.org/wiki/Electroacupuncture. Suchelectrical stimulation is known as electroacupuncture (EA). According toAcupuncture Today, a trade journal for acupuncturists:“Electroacupuncture is quite similar to traditional acupuncture in thatthe same points are stimulated during treatment. As with traditionalacupuncture, needles are inserted on specific points along the body. Theneedles are then attached to an external device that generatescontinuous electric pulses using small clips. These devices are used toadjust the frequency and intensity of the impulse being delivered,depending on the condition being treated. Electroacupuncture uses twoneedles at a time so that the impulses can pass from one needle to theother. Several pairs of needles can be stimulated simultaneously,usually for no more than 30 minutes at a time.” “Acupuncture Today:Electroacupuncture”. 2004 Feb. 1 (retrieved on-line 2006 Aug. 9 athttp://www.acupuncturetoday.com/abc/electroacupuncture.php).

U.S. Pat. No. 7,203,548, issued to Whitehurst et al., discloses use ofan implantable miniature neurostimulator, referred to as a“microstimulator,” that can be implanted into a desired tissue locationand used as a therapy for cavernous nerve stimulation. Themicrostimulator has a tubular shape, with electrodes at each end.

Other patents of Whitehurst et al. teach the use of this small,microstimulator, placed in other body tissue locations, including withinan opening extending through the skull into the brain, for the treatmentof a wide variety of conditions, disorders and diseases. See, e.g., U.S.Pat. No. 6,950,707 (obesity and eating disorders); U.S. Pat. No.7,003,352 (epilepsy by brain stimulation); U.S. Pat. No. 7,013,177 (painby brain stimulation); U.S. Pat. No. 7,155,279 (movement disordersthrough stimulation of Vagas nerve with both electrical stimulation anddrugs); U.S. Pat. No. 7,292,890 (Vagas nerve stimulation); U.S. Pat. No.6,735,745 (headache and/or facial pain); U.S. Pat. No. 7,440,806(diabetes by brain stimulation); U.S. Pat. No. 7,610,100(osteoarthritis); and U.S. Pat. No. 7,657,316 (headache by stimulatingmotor cortex of brain). The microstimulator patents of Whitehurst et.al., or other similar patents, either require electronics and battery ina coil on the outside of the body or a coil on the outside that enablesthe recharging of a rechargeable battery. The use of an outside coil,complex electronics, and the tubular shape of the microstimulator haveall limited the commercial feasibility of the microstimulator device andapplications described in the Whitehurst patents.

Techniques for using electrical devices, including external EA devices,for stimulating peripheral nerves and other body locations for treatmentof various maladies are known in the art. See, e.g., U.S. Pat. Nos.4,535,784; 4,566,064; 5,195,517; 5,250,068; 5,251,637; 5,891,181;6,006,134; 6,393,324; 6,516,227; 7,171,266; 7,171,266; and 7801,615. Seealso U.S. Patent Publications Nos. US 2009/0292341 A1; US 2005/0234533A1; and US 2005/0107832 A1; US 2003/0158588 A1; US 2007/0255319 A1. Themethods and devices disclosed in these patents and publications,however, typically utilize (i) relatively large implantable stimulatorshaving long leads that must be tunneled through tissue over an extendeddistance to reach the desired stimulation site, (ii) external devicesthat must interface with implanted electrodes via percutaneous leads orwires passing through the skin, (iii) inefficient and power-consumingwireless transmission schemes, and/or (iv) implantable devices thatrequire a rechargeable battery or other power source. Such devices andmethods are still far too invasive, or are ineffective, and thus aresubject to the same limitations and concerns, as are the previouslydescribed electrical stimulation devices.

From the above, it is seen that there is a need in the art for a lessinvasive device and technique for electroacupuncture stimulation ofacupoints that does not require the continual use of needles insertedthrough the skin, or long insulated wires implanted or inserted intoblood vessels, for the purpose of treating chronic low back pain.

BRIEF DESCRIPTION OF THE DRAWINGS

The accompanying drawings illustrate various embodiments and are a partof the specification. The illustrated embodiments are merely examplesand do not limit the scope of the disclosure. Throughout the drawings,identical or similar reference numbers designate identical or similarelements.

FIG. 1 is a perspective view of a leadless implantableelectroacupuncture device (referred to herein as an “IEAD” and as an “EAdevice”) made in accordance with the teachings presented herein.

FIG. 1A illustrates the lumbar region of a patient and shows thelocation of some representative acupoints in that region, e.g., BL52(also sometimes referred to as acupoint Zhishi), BL23 (also sometimesreferred to as acupoint Shenshu) and GV4 (also sometimes referred to asacupoint Mingmen).

FIG. 1B illustrates the location of acupoints BL22, BL23, BL24, BL25 andBL26, any one of which, or any combination of which, may serve as atarget stimulation site(s) at which an IEAD may be implanted for thetreatment of chronic low back pain.

FIG. 1C shows a sectional view of an IEAD implanted at a selected targetstimulation site, and illustrates the electric field gradient linescreated when an electroacupuncture (EA) pulse is applied to the tissuethrough the central electrode and ring electrode attached to the bottomsurface and perimeter edge, respectively, of the IEAD housing.

FIG. 2 shows a plan view of one surface of the IEAD housing illustratedin FIG. 1.

FIG. 2A shows a side view of the IEAD housing illustrated in FIG. 1.

FIG. 3 shows a plan view of the other side, indicated as the “BackSide,” of the IEAD housing or case illustrated in FIG. 1.

FIG. 3A is a sectional view of the IEAD of FIG. 3 taken along the lineA-A of FIG. 3.

FIG. 4 is a perspective view of the IEAD housing, including afeed-through pin, before the electronic components are placed therein,and before being sealed with a cover plate.

FIG. 4A is a side view of the IEAD housing of FIG. 4.

FIG. 5 is a plan view of the empty IEAD housing shown in FIG. 4.

FIG. 5A depicts a sectional view of the IEAD housing of FIG. 5 takenalong the section line A-A of FIG. 5.

FIG. 5B shows an enlarged view or detail of the portion of FIG. 5A thatis encircled with the line B.

FIG. 6 is a perspective view of an electronic assembly, including abattery, adapted to fit inside of the empty housing of FIG. 4 and FIG.5.

FIGS. 6A and 6B show a plan view and side view, respectively, of theelectronic assembly shown in FIG. 6.

FIG. 7 is an exploded view of the IEAD assembly of the IEAD of FIG. 1,illustrating its constituent parts.

FIG. 7A shows an alternative embodiment of the IEAD housing adapted tohave a short extension lead affixed to the cathode electrode located onthe housing, with a distal cathode electrode located at the distal endof the extension lead.

FIG. 7B shows a proximal end of the short extension lead of FIG. 7Aattached to the central cathode electrode located on the IEAD housing,whereby the combination of the IEAD housing and extension lead allow thecathode electrode (located at the distal end of the extension lead) tobe positioned closer to a desired target location.

FIG. 7C shows a proximal end of the short extension lead of FIG. 7Aattached to the perimeter edge of the IEAD housing, and includes the useof a strain gauge to help better secure the proximal end of the lead toits desired attachment location on the perimeter edge.

FIG. 7D schematically illustrates the IEAD of FIG. 7B or 7C positionedso as to place the cathode electrode closer to the lumbar nerve anddorsal roots while the IEAD housing remains subcutaneously positioned ata desired acupoint.

FIG. 7E includes a series of figures, (a), (b), (c) and (d), that showone process that may be used to “grow” or extend a short extension leadon the central cathode electrode on the IEAD housing using a depositionor equivalent process.

FIG. 8A illustrates a functional block diagram of the electroniccircuits used within an IEAD of the type described herein.

FIG. 8B shows a basic boost converter circuit configuration, and is usedto model how the impedance of the battery R_(BAT) can affect itsperformance.

FIG. 9A illustrates a typical voltage and current waveform for thecircuit of FIG. 8 when the battery impedance R_(BAT) is small.

FIG. 9B shows the voltage and current waveform for the circuit of FIG.8B when the battery impedance R_(BAT) is large.

FIG. 10 shows an exemplary boost converter circuit and a functionalpulse generation circuit configuration for use within the IEAD.

FIG. 11 shows an alternate boost converter circuit configuration and afunctional pulse generation circuit for use within the IEAD.

FIG. 12 shows a refinement of the circuit configuration of FIG. 11.

FIG. 13A shows an exemplary schematic configuration for an implantableelectroacupunture device (IEAD) that utilizes the boost converterconfiguration shown in FIG. 10.

FIG. 13B shows current and voltage waveforms associated with theoperation of the circuit shown in FIG. 13A.

FIG. 14 shows another exemplary schematic configuration for an IEADsimilar to that shown in FIG. 13A, but which uses an alternate outputcircuitry configuration for generating the stimulus pulses.

FIG. 14A depicts yet a further exemplary schematic configuration for anIEAD similar to that shown in FIG. 13A or FIG. 14, but which includesadditional enhancements and circuit features.

FIGS. 14B and 14C show timing waveform diagrams that illustrate theoperation of the circuit of FIG. 14 before (FIG. 14B) and after (FIG.14C) the addition of a cascode stage to the IEAD circuitry that removessome undesirable transients from the leading edge of the stimulus pulse.

FIGS. 14D and 14E illustrate timing waveform diagrams that show theoperation of the circuit of FIG. 14 before (FIG. 14D) and after (FIG.14E) the addition of circuitry that addresses a delay when starting thecurrent regulator U3 for low amplitude stimulus pulses.

FIG. 15 shows a reverse trapezoidal waveform of the type that isgenerated by the pulse generation circuitry of the IEAD, and furtherillustrates one approach for achieving the desired reverse trapezoidalwaveform shape.

FIG. 15A shows a timing waveform diagram of representative EAstimulation pulses generated by the IEAD device during a stimulationsession.

FIG. 15B shows a timing waveform diagram of multiple stimulationsessions, and illustrates the waveforms on a more condensed time scale.

FIG. 15C shows a timing waveform diagram similar to FIG. 15A, butwherein the stimulation session is divided into two sub-sessions, onesub-session with stimulation being applied at a first frequency, and theother sub-session having stimulation applied at a second frequency.

FIG. 16 shows a state diagram that depicts the various states the IEADmay assume as controlled by an external magnet.

FIGS. 17A, 17B, and 17C respectively show three lead configurations thatmay be used with an IEAD in accordance with the teachings presentedherein.

FIG. 18A shows an exemplary embodiment of an IEAD that has a detachablelead attached to a header assembly mounted on a perimeter edge of theIEAD.

FIG. 18B shows the embodiment shown in FIG. 18A, but with the lead beingdetached from the header assembly.

FIG. 18C shows a sectional side view taken along the line 18C-18C of theIEAD shown in FIG. 18B.

FIG. 18D shows a perspective view of the electrode at the distal end thedetachable lead used in FIG. 18B.

FIG. 19 illustrates a cross-sectional view of the detachable lead usedin FIG. 18B.

FIGS. 20A, 20B and 20C show a sequence of views associated with mountingthe header assembly to the perimeter edge of the case of the IEAD;wherein FIG. 20A depicts the header assembly prior to mounting, FIG. 20Billustrates the location on the perimeter edge of the IEAD case wherethe header assembly is mounted relative to the location of the radialfeed-through pin, and FIG. 20C shows the header assembly after beingmounted on the perimeter edge.

FIG. 21 illustrates the silicone jacket that is placed over the IEAD andheader assembly once the header assembly has been mounted to theassembled IEAD case.

FIGS. 22A and 22B respectively illustrate sectional views of the headerassembly mounted on the edge of the assembled IEAD when the proximal endof the detachable lead is not inserted into the header assembly (FIG.22A) and when proximal end of the detachable lead is inserted into theheader assembly (FIG. 22B).

FIG. 22C shows a perspective view of a Bal Seal used within the headerassembly.

In addition to the teachings provided by the above drawings, and theiraccompanying text, additional examples of alternative symmetricalelectrode configurations, non-symmetrical electrode configurations, andrepresentative code that may be used in the micro-controller IC (e.g.,U2 in FIG. 14) to control the basic operation and programming of theIEAD, may be found in Applicant's earlier application, application Ser.No. 13/598,582, filed Aug. 29, 2012 and issued as U.S. Pat. No.8,965,511, and/or its appendices, which application and its appendicesare incorporated herein by reference.

DETAILED DESCRIPTION

Systems and methods for treating low back pain are described herein. Insome examples, the systems and methods may provide an implantableelectroacupuncture device (IEAD) that treats chronic low back painthrough application of electroacupuncture (EA) stimulation pulsesapplied at a target tissue location. The target tissue locationcomprises tissue underlying, or in the vicinity of, at least one ofacupoints GV4, BL22, BL23, BL24, BL25, and BL26, all of which arelocated in the lumbar region about 1.5 inches lateral to the posteriormedian line. The IEAD may include: (1) a small IEAD housing having aheader formed thereon into which a unipolar lead having a distalelectrode located at or near its distal tip (hereafter “distalelectrode”), may be detachably connected, and at least one otherelectrode formed as part of the IEAD housing (hereafter “caseelectrode”), (2) pulse generation circuitry located within the IEADhousing that delivers EA stimulation pulses to the patient's body tissueat at least one of acupoints GV4, BL22, BL23, BL24, BL25, and BL26through the distal and case electrodes, (3) a primary battery alsolocated within the IEAD housing that provides the operating power forthe IEAD to perform its intended function, and (4) a sensor locatedwithin the IEAD housing that is responsive to operating commandswirelessly communicated to the IEAD from a non-implanted location. Theseoperating commands allow limited external control of the IEAD, such asON/OFF and EA stimulation pulse amplitude and/or frequency adjustment.

In some examples, the IEAD housing is made from two main parts: (1) acoin-sized and -shaped housing having a nominal diameter of about 25 mm,and a thickness of only 2 to 3 mm, originally made as a leadless device,having a case electrode and a ring electrode around the perimeter of thecoin-sized and shaped housing; and (2) a header assembly that replacesthe ring electrode and is attached to one segment of the perimeter ofthe coin-sized and shaped housing, and including a female connectorformed within the header assembly adapted to receive a proximal end ofthe lead on which the distal electrode is found, this female connecterbeing electrically connected to a radial feed-through pin originallyconnected to the ring electrode, but which ring electrode is notutilized in this leaded embodiment of the systems and methods describedherein.

In some examples, a relatively short, flexible, smooth, unipolarcatheter lead may be attached at its proximal end to the centralelectrode located on the first surface of the IEAD housing. A suitableinsulator then covers the central electrode, including the area wherethe proximal end of the catheter lead is attached, e.g., welded, to thecentral electrode surface, so that the only electrical connection thatcan be made with the central electrode from a location external to theIEAD housing is from a distal end of the catheter lead. The distal endof the catheter lead thus functions as the central electrode. The distalend of the catheter lead is then positioned near the lumbar nerve ordorsal root ganglion of at least one of acupoints GV4, BL22, BL23, BL24,BL25 and BL26. Using such a catheter lead attached to the centralelectrode allows the IEAD to still be implanted near the specifiedtarget acupoint(s), yet further facilities a more efficient and directstimulation of the lumbar nerve(s) and or dorsal root ganglion(s) in abody tissue location (near the vertebra) where it is difficult toimplant the IEAD housing.

Alternatively, the short, smooth, unipolar catheter lead may have itsproximal end attached to the annular ring electrode located around theperimeter of the IEAD housing. When this is done, the polarity of theannular ring electrode may be selected to have it function as a cathode.An advantage of having the short lead attached to the edge of the IEADhousing is that the attachment process can be done with strain relief,and thereby provide a more reliable attachment and manufacturingprocess.

In some examples, the polarity of the original coin-sized and -shapedhousing may be reversed, with the anode electrode being the caseelectrode and with the distal electrode being a cathode electrode. Thecathode electrode, located at the distal end of a catheter lead that maybe up to 50 mm long (or, in some instances, even longer), is detachablyconnected to the IEAD radial feed through pin by inserting the proximalend of the catheter lead into the connector in the header assembly.Using a detachable lead in this manner simplifies the implantationprocess so that the surgeon can carefully insert the distal tipelectrode into a desired target simulation point, typically directlyadjacent the vertebrae in the lower lumbar region, and then detachablyconnect the proximal end of the positioned lead to the IEAD case, andplacing the case in a suitable implant pocket some distance, e.g, up to50 mm distance, away from the target tissue locationi.

The pulse generation circuitry located within the IEAD housing iscoupled to the at least two electrodes, e.g., the case electrode and thedistal electrode. This pulse generation circuitry is configured togenerate EA stimulation pulses in accordance with a specifiedstimulation regimen. This stimulation regimen defines the duration andrate at which a stimulation session is applied to the patient. Thestimulation regimen requires that the stimulation session have aduration of no more than T3 minutes and a rate of occurrence of no morethan once every T4 minutes.

Advantageously, the duty cycle of the stimulation sessions, i.e., theratio of T3/T4, is very low, no greater than 0.05. A representativevalue for T3 is 30 minutes, and a representative value for T4 is 7 days.The individual EA stimulation pulses that occur within the stimulationsession also have a duty cycle measured relative to the period (wherethe “period” is the time interval equal to the inverse of the frequencyor rate of the stimulation pulses) of no greater than 3%. Arepresentative pulse width and frequency for the EA stimulation pulsesis 0.1 milliseconds, occurring at a pulse rate of 2 Hz. In someinstances, the pulse rate may be toggled between a low pulse rate, e.g.,1 to 15 Hz, and a higher pulse rate, e.g., 15 to 100 Hz. In suchinstance—when toggling between a low and a high stimulation pulserate—the toggling rate may be set to occur every 3 to 6 seconds.

The primary battery contained within the IEAD housing and electricallycoupled to the pulse generation circuitry has a nominal output voltageof 3 volts, and an internal battery impedance that is at least 5 ohms,and may be as high as 150 ohms or more. Advantageously, electroniccircuitry within the IEAD housing controls the value of theinstantaneous surge current that may be drawn from the battery in orderto prevent any large drops in the battery output voltage. Avoiding largedrops in the battery output voltage assures that the circuits within theIEAD will continue to operate as designed without failure. Being able touse a primary battery that has a relatively high internal impedanceallows the battery to be thinner, and thus allows the device to bethinner and more easily implanted. The higher internal impedance alsoopens the door to using relatively inexpensive commercially-availabledisc batteries as the primary battery within the IEAD, thereby greatlyenhancing the manufacturability of the IEAD and significantly loweringits cost.

In some examples, a first method for treating chronic low back pain in apatient uses a leaded, coin-sized implantable electroacupuncture device(IEAD). Such IEAD is powered by a small disc battery having a specifiednominal output voltage of about 3.0 volts, and having an internalimpedance of at least 5 ohms.

The IEAD used to practice this first method is configured, usingelectronic circuitry within the IEAD, to generate EA stimulation pulsesin accordance with a specified stimulation regimen. The EA stimulationpulses generated in accordance with this stimulation regimen are appliedto the patient's tissue through the case electrode and through thedistal electrode located at the end of the detachable lead, whichdetachable lead is connected to the IEAD circuitry through the headerassembly.

Using such an IEAD, the method for treating chronic low back painprovided by this first method includes the steps of: (a) implanting thedistal electrode, of a short unipolar implantable lead, below the skinsurface of the patient at or near a selected target tissue location,where the target tissue location comprises tissue underlying, or in thevicinity of, at least one of acupoints GV4, BL22, BL23, BL24, BL25 andBL26; (b) detachably connecting a proximal end of the implantable leadto the header assembly of the IEAD; (c) implanting the IEAD, with thelead attached, in body tissue that is near, e.g., within 50 mm, of thetarget tissue location; and (d) enabling the IEAD to provide stimulationpulses in accordance with a specified stimulation regimen.

The specified stimulation regimen, when enabled, provides a stimulationsession at a rate of one stimulation session every T4 minutes, with eachstimulation session having a duration of T3 minutes. The ratio of T3/T4must be no greater than 0.05. An exemplary stimulation session time T3is 30 minutes, but T3 could be as short as 10 minutes or as long as 60minutes. An exemplary time between stimulation sessions, T4, is 7 days,but it could be as short as 1 day or as long as 14 days, as needed, tosuit the needs of a particular patient.

In some embodiments, the time period between stimulation sessions, T4,may itself be a variable that increases from an initial value, T4 (min),to a final value, T4 (final), where T4 (min) is a desired initial value,e.g., 1 day (1440 minutes), and T4 (final) is a desired final value,e.g., 7 days (10,080 minutes). In such situation, i.e., where T4initially varies, the change of T4 between T4 (min) to T4 (final)follows a prescribed ramp-up sequence, e.g., starting at T4 (min), T4doubles after each stimulation session until the desired value of T4(final) is reached. Thus, for example, if T4 (min) is 1 day, and T4(final) is 7 days, the value of T4 may vary as follows once thestimulation sessions begin: T4=1 day, 2 days, 4 days and 7 days.

Overview

Disclosed herein is an implantable, self-contained, leadlesselectroacupuncture (EA) device having at least two electrode contactsmounted on the surface of its housing. The EA device disclosed herein isadapted to treat chronic low back pain in a patient. In one embodiment,the electrodes on the surface of the EA device include a central cathodeelectrode on a bottom side of the housing, and an annular anodeelectrode that surrounds the cathode. In another embodiment, the anodeannular electrode is a ring electrode placed around the perimeter edgeof the coin-shaped housing.

The EA device can be leadless. This means there are no leads orelectrodes at the distal end of leads (common with most implantableelectrical stimulators) that have to be positioned and anchored at adesired stimulation site. Also, because there are no leads, no tunnelingthrough body tissue or blood vessels is required in order to provide apath for the leads to return and be connected to a tissue stimulator(also common with most electrical stimulators).

Alternatively, in order to improve the ability of the IEAD to direct thestimulation precisely to a desired target stimulation site, e.g.,between specified lumbar vertebra, the EA device may stimulate using adistal electrode at the end of a relatively short, e.g., 50 mm long,monopolar lead attached to the IEAD and a reference, or return,electrode formed on the case of the IEAD. Such monopolar lead may bepermanently attached to the IEAD, or detachably connected to the IEAD.If detachably connected, the connection may be made directly at a headerassembly mounted onto a perimeter edge of the IEAD, or at a distalconnector of a short pigtail lead that has its proximal end permanentlyattached to the IEAD.

The EA device is adapted to be implanted through a very small incision,e.g., less than 2-3 cm in length, directly adjacent to a selected targetstimulation site, e.g., an acupuncture site (“acupoint”) known to affecta chronic low back pain condition of a patient.

The EA device is self-contained. It includes a primary battery toprovide its operating power. It includes all of the circuitry it needs,in addition to the battery, to allow it to perform its intended functionfor several years. Once implanted, the patient will not even know it isthere, except for a slight tingling that may be felt when the device isdelivering stimulus pulses during a stimulation session. Also, onceimplanted, the patient can just forget about it. There are nocomplicated user instructions that must be followed. Just turn it on. Nomaintenance is needed. Moreover, should the patient want to disable theEA device, i.e., turn it OFF, or change stimulus intensity, he or shecan do so using, e.g., an external magnet.

The EA device can operate for several years because it is designed to bevery efficient. Stimulation pulses applied by the EA device at aselected target stimulation site, e.g., a specified acupoint, throughits electrodes formed on its case are applied at a very low duty cyclein accordance with a specified stimulation regimen. The stimulationregimen applies EA stimulation during a stimulation session that lastsat least 10 minutes, typically 30 minutes, and rarely longer than 60minutes. These stimulation sessions, however, occur at a very low dutycycle. In one exemplary treatment regimen, for example, a stimulationsession having a duration of 30 minutes is applied to the patient justonce a week. The stimulation regimen, and the selected acupoint at whichthe stimulation is applied, are designed and selected to provideefficient and effective EA stimulation for the treatment of thepatient's chronic low back pain.

The EA device is, compared to most implantable medical devices,relatively easy to manufacture and uses few components. This not onlyenhances the reliability of the device, but keeps the manufacturingcosts low, which in turn allows the device to be more affordable to thepatient. One exemplary feature included in the mechanical design of theEA device is the use of a radial feed-through assembly to connect theelectrical circuitry inside of its housing to one of the electrodes onthe outside of the housing. The design of this radial feed-through pinassembly greatly simplifies the manufacturing process. The processplaces the temperature sensitive hermetic bonds used in the assembly—thebond between a pin and an insulator and the bond between the insulatorand the case wall—away from the perimeter of the housing as the housingis hermetically sealed at the perimeter with a high temperature laserwelding process, thus preserving the integrity of the hermetic bondsthat are part of the feed-through assembly.

In operation, the EA device is safe to use. There are no horrificfailure modes that could occur. Because it operates at a very low dutycycle (i.e., it is OFF much, much more than it is ON), it generateslittle heat. Even when ON, the amount of heat it generates is not much,less than 1 mW, and is readily dissipated. Should a component or circuitinside of the EA device fail, the device will simply stop working. Ifneeded, the EA device can then be easily explanted.

Another exemplary feature included in the design of the EA device is theuse of a commercially-available battery as its primary power source.Small, thin, disc-shaped batteries, also known as “coin cells,” arequite common and readily available for use with most modern electronicdevices. Such batteries come in many sizes, and use variousconfigurations and materials. However, insofar as the inventors orApplicant are aware, such batteries have never been used in implantablemedical devices previously. This is because their internal impedance is,or has always thought to have been, much too high for such batteries tobe of practical use within an implantable medical device where powerconsumption must be carefully monitored and managed so that the device'sbattery will last as long as possible, and so that dips in the batteryoutput voltage (caused by any sudden surge in instantaneous batterycurrent) do not occur that could compromise the performance of thedevice. Furthermore, the energy requirements of other active implantabletherapies are far greater than can be provided by such coin cellswithout frequent replacement.

The EA device disclosed herein advantageously employs power-monitoringand power-managing circuits that prevent any sudden surges in batteryinstantaneous current, or the resulting drops in battery output voltage,from ever occurring, thereby allowing a whole family ofcommercially-available, very thin, high-output-impedance, relatively lowcapacity, small disc batteries (or “coin cells”) to be used as the EAdevice's primary battery without compromising the EA device'sperformance. As a result, instead of specifying that the EA device'sbattery must have a high capacity, e.g., greater than 200 mAh, with aninternal impedance of, e.g., less than 5 ohms, which would eitherrequire a thicker battery and/or preclude the use ofcommercially-available coin-cell batteries, the EA device of the presentsystems and methods can readily employ a battery having a relatively lowcapacity, e.g., less than 60 mAh, and a high battery impedance, e.g.,greater than 5 ohms.

Moreover, the power-monitoring, power-managing, as well as the pulsegeneration, and control circuits used within the EA device arerelatively simple in design, and may be readily fashioned fromcommercially-available integrated circuits (IC's) orapplication-specific integrated circuits (ASIC's), supplemented withdiscrete components, as needed. In other words, the electronic circuitsemployed within the EA device need not be complex nor expensive, but aresimple and inexpensive, thereby making it easier to manufacture and toprovide it to patients at an affordable cost.

An exemplary application for an EA device made in accordance with theteachings presented herein is to treat chronic low back pain. Thus, thedescription that follows describes in much more detail an EA device thatis especially suited to be used to treat chronic low back pain. However,it is to be understood that the systems and methods described herein arenot limited to treating only chronic low back pain.

In at least one embodiment, the EA device has a short lead attached toone of its electrodes, e.g., the cathode electrode. This makes itpossible in some situations where chronic low back pain is beingtreated, to position a unipolar electrode, typically a unipolar cathodeelectrode, closer to the lumbar nerve and dorsal roots while the housingof the EA device remains subcutaneously positioned at a desiredacupoint.

In another embodiment, the short lead attached to the IEAD is detachablyconnected via a connector included within a header assembly mounted on aperipheral edge of the IEAD.

Definitions

As used herein, “annular”, “circumferential”, “circumscribing”,“surrounding” or similar terms used to describe an electrode orelectrode array, or electrodes or electrode arrays, (where the phrase“electrode or electrode array,” or “electrodes or electrode arrays,” isalso referred to herein as “electrode/array,” or “electrodes/arrays,”respectively) refers to an electrode/array shape or configuration thatsurrounds or encompasses a point or object, such as another electrode,without limiting the shape of the electrode/array or electrodes/arraysto be circular or round. In other words, an “annular” electrode/array(or a “circumferential” electrode/array, or a “circumscribing”electrode/array, or a “surrounding” electrode/array), as used herein,may be many shapes, such as oval, polygonal, starry, wavy, and the like,including round or circular.

An “implantable electroacupuncture device”, or “IEAD”, refers to a thin,coin-sized, self-contained, neural stimulator that can be implantedsubcutaneously at or near a desired target stimulation site, e.g., aspecified acupoint. An IEAD may sometimes be referred to herein as asubcutaneous neural stimulator (SNS) device. An exemplary IEAD or SNS isleadless, but some embodiments may include a short monopolar lead.

“Nominal” or “about” when used with a mechanical dimension, e.g., anominal diameter of 23 mm, means that there is a tolerance associatedwith that dimension of no more than plus or minus (+/−) 5%. Thus, adimension that is nominally 23 mm means a dimension of 23 mm+/−1.15 mm(0.05×23 mm=1.15 mm). “Nominal” when used to specify a battery voltageis the voltage by which the battery is specified and sold. It is thevoltage you expect to get from the battery under typical conditions, andit is based on the battery cell's chemistry. Most fresh batteries willproduce a voltage slightly more than their nominal voltage. For example,a new nominal 3 volt lithium coin-sized battery will measure more than3.0 volts, e.g., up to 3.6 volts under the right conditions. Sincetemperature affects chemical reactions, a fresh warm battery will have agreater maximum voltage than a cold one. For example, as used herein, a“nominal 3 volt” battery voltage is a voltage that may be as high as 3.6volts when the battery is brand new, but is typically between 2.7 voltsand 3.4 volts, depending upon the load applied to the battery (i.e., howmuch current is being drawn from the battery) when the measurement ismade and how long the battery has been in use.

As explained in more detail below, an electroacupunture modulationscheme need not be continuous, thereby allowing the implanted EA deviceto use a small, high density, power source to provide suchnon-continuous EA modulation. (Here, it should be noted that “EAmodulation,” as that phrase is used herein, is the application ofelectrical stimulation pulses, at low intensities, low frequencies andlow duty cycles, to at least one of the target stimulation sites, e.g.,an acupuncture site that has been identified as affecting a particularcondition, e.g., chronic low back pain, of the patient. As a result, theEA device can be very small. And, because the electrodes form anintegral part of the housing of the EA device, the EA device may thus beimplanted directly at (or very near to) the desired target tissuelocation, e.g., the target stimulation site, such as the targetacupoint.

In summary, and as explained more fully below in conjunction with thedescription of the treatment method for treating chronic low back pain,the basic approach of EA stimulation includes: (1) identify anacupoint(s) or other target stimulation site that may be used to treator mediate the particular illness, condition or deficiency that hasmanifest itself in the patient, e.g., chronic low back pain; (2) implantan EA device, made as described herein, so that its electrodes arelocated to be near or on the identified acupoint(s) or other targetstimulation site; (3) apply EA modulation, having a low intensity, lowfrequency, and low duty cycle through the electrode(s) of the EA deviceso that electrical stimulation pulses flow through the tissue at thetarget stimulation site following a prescribed stimulation regimen overseveral weeks or months or years. At any time during this EA stimulationregimen, the patient's illness, condition or deficiency may be evaluatedand, as necessary, the parameters of the EA modulation applied duringthe EA stimulation regimen may be adjusted or “tweaked” in order toimprove the results obtained from the EA modulation.

Conditions Treated

Low back pain is a major health problem in western nations causing highmedical expenses, absenteeism in the workplace and disablement. Low backpain is characterized as chronic when it persists for at least threemonths; otherwise, it is called “acute.”

The present methods and systems treat patients with chronic low backpain. However, the cause of such pain may vary from patient to patientand it may yet be determined that a certain origin of chronic low backpain is more treatable with the present methods and systems thananother. For example, it is known that in a selection of patients with aduration of low back pain of at least 6 weeks and a baseline visualanalogue scale of 50 mm, acupuncture applied in the chosen region wassuccessful. See, Molsberger, A. F., Mau, J., Pawelec, D. B., & Winkler,J. (2002). Does acupuncture improve the orthopedic management of chroniclow back pain—a randomized, blinded, controlled trial with 3 monthsfellow up. Pain, 99(3), 579-587 (hereafter, “Molsberger 2002”).

Additionally, it has been reported in the acupuncture literature thatpatients with a low back pain origin of intervertebral disk profusionhave been treated successfully by applying conventional acupuncture inthe lumbar region about 1.5 inches lateral to the posterior median lineSee, Zhou, X. P., & Huang, C. J. (2010). Influence of acupuncture plusLONG's manual manipulations on functional improvement in lumbarintervertebral disc protrusion. Journal of Acupuncture and TuinaScience, 8, 375-379. For a study showing success in patients withrelapsed lumbar disk herniation after disc surgery, see, Wu, Y. C.,Wang, C. M., Zhang, J. F., & Li, S. S. (2010). Clinical observation onthe treatment of relapsed lumbar disc herniation after disc surgery byacupuncture plus medication. Journal of Acupuncture and Tuina Science,8, 315-317.

It has also been shown that acupuncture in the region brought aboutpositive results in patients with pain due to lumbar strain andhyperplastic spondylitis. See, Lian, N., Liu, J. B., Torres, F., Yan, Q.M., & Guerra, E. (2005). Improvement of dermal needle and bodyacupuncture on pain due to lumbar strain and hyperplastic spondylitis.

Patients with low back pain second to degenerative disk disease havebeen successfully treated with a similar treatment modality. See,Ghoname, E. A., Craig, W. F., White, P. F., Ahmed, H. E., Hamza, M. A.,Henderson, B. N., . . . & Gatchel, R. J. (1999). Percutaneous electricalnerve stimulation for low back pain: a randomized crossover study. JAMA:the journal of the American Medical Association, 281(9), 818-823.

It has also been shown that acupuncture applied in the lumbar region hasbeen shown to bring about significant positive benefit in patients witha long history of low back pain (e.g. 10 years on average). See,Molsberger 2002. See also, Yeung, C. K., Leung, M. C., & Chow, D. H.(2003). The use of electro-acupuncture in conjunction with exercise forthe treatment of chronic low-back pain. The Journal of Alternative &Complementary Medicine, 9(4), 479-490.

Applicant believes the mechanism of action achieved through use of themethods and systems described herein is both central and local innature. In a study published in 1984, electroacupuncture in theidentified region was performed and tests were designed to determinewhether a central mechanism of action existed, thus improving both lowback pain and experimental pain in the forearms, or whether a localmechanism of action existed, thus only reducing the low back pain. See,Price, D. D., Rafii, A., Watkins, L. R., & Buckingham, B. (1984). Apsychophysical analysis of acupuncture analgesia, Pain, 19(1), 27-42. Itwas determined that both mechanisms were present based upon patientresponse to experimental pain and report of low back pain.

Furthermore, the involvement of opioid receptors and opiate peptides hasbeen put forth as highly relevant to the mechanism. In one study, it wasshown that low frequency electroacupuncture that reduced pain in tenpatients was also associated with increases in beta endorphin levelsfound in the cerebrospinal fluid (CSF). It is suggested that theanalgesia observed may be mediated by the release into the CSF of theendogenous opiate, beta-endorphin. See, Clement-Jones, V., Tomlin, S.,Rees, L., Mcloughlin, L., Besser, G. M., & Wen, H. L. (1980). Increasedβ-endorphin but not met-enkephalin levels in human cerebrospinal fluidafter acupuncture for recurrent pain. The Lancet, 316(8201), 946-949.

In another study published in Korean with an English abstract, it wassimilarly seen that acupuncture produced an analgesic effect andincreased beta-endorphin levels in chronic low back pain patients.Additionally, cortisol and ACTH levels changed 60 minutes followingacupucnture. See, Song, J. G., Lim, G. S., & Kim, K. S. (1989). Effectsof acupuncture on the plasma levels of β endorphine, ACTH and cortisolin chronic low back pain. The Journal of Korean Acupuncture &Moxibustion Society, 6, 63-82.

There is some evidence in humans, other than experimental pain tests,that the mechanism may be partially central in nature. In a studyperformed by a group frequently cited in this application,electroacupuncture was performed on a region of the back similar to theacupoints described by in this application but for the treatment of neckpain. The electroacupuncture was successful, suggesting that a centralmechanism might be involved. See, White 2000.

Furthermore, an important player in acupuncture research on pain, J SHan, has written about the involvement of opioid receptors and theirchemicals, namely, dynorphins and enkaphalins. See, Han, J. S. (2011).Acupuncture analgesia: areas of consensus and controversy. Pain, 152(3),S41-S48. See also, Sjölund, B., Terenius, L, & Eriksson, M. (1977).Increased Cerebrospinal Fluid Levels of Endorphins afterElectro-Acupuncture. Acta Physiologica Scandinavica, 100(3), 382-384. Ingeneral, the writings of Han suggest that the mechanism of action forreduction of pain by acupuncture likely involves modulation of opioidreceptors and their chemicals.

Locations Stimulated and Stimulation Paradigms/Regimens

Acupuncture for low back pain historically utilizes acupoints (sometimesreferred to as “points”) located throughout the body with particularfocus on the back region. As Traditional Chinese Medicine prescribes,the individual is treated as a whole based on the particularity of hissymptoms. Thus, traditionally, about a dozen points are utilized in asingle acupuncture session.

Applicant, however, was determined to narrow the necessary points. Itdid so based on identification and analysis of the most commonlyutilized points, and a thorough comparison of successful acupuncturestudies utilizing a small number of points in order to determine whichpoints were most responsible for the positive effect.

Applicant has identified a handful of points most appropriate as thetarget location for stimulation, all laying on a single meridian called“bladder” and identified by the two letters, “B-L” or alternatively,called “urinary bladder” and identified by the two letters, “U-B”.Points on this meridian are bilateral acupoints, meaning that there aretwo points for each name or number combination, e.g., BL22 is located oneither side of the spine. Applicant identifies the following acupointslocated along the bladder meridian in the lumbar region and within closeproximity of one another: BL22 (“Sanjiaoshu”), BL23 (“Shenshu”), BL24(“Qihaishu”), BL25 (“Dachangshu”), and BL26 (“Guanyuanshu”). Eachacupoint may have a number of names to identify the point. As a generalrule, one or two letters usually signifies the meridian and then anumber to identify where the acupoint falls on that meridian.

In one electroacupuncture study for the treatment of low back pain wheresuccess was found, the points stimulated are relatively few. See, Yeung,C. K, Leung, M. C., & Chow, D. H. (2003). The use of electro-acupuncturein conjunction with exercise for the treatment of chronic low-back pain.The Journal of Alternative & Complementary Medicine, 9(4), 479-490(hereafter, “Yeung 2003”).

Most impressively, however, is the commonality of the acupoints BL23 andBL25 with more than a handful of studies identified by Applicant assufficiently rigorous, successful, and supportive of its methods andsystems.

Those two acupoints are found to be most commonly utilized for thetreatment of low back pain. See, Xia, Y., & Wu, G. (Eds.). (2010).Acupuncture therapy for neurological diseases: a neurobiological view.Springer (hereafter, “Xia 2010”).

For example, a large number of patients, several hundred, with low backpain were treated successfully with just three acupoints on the backincluding BL23 and BL25. See, Wang J. (1996). The Effect of Acupunctureon 492 Cases of Lumbago. Shanghai Acupuncture Journal, 15(5): 28-29 (InChinese with English translation).

The location of the chosen sites for stimulation, identified by theftacupoints, is next described. “BL22” is located in the lumbar region atthe same level as the inferior border of the spinous process of thefirst lumbar vertebra (L1), about 1.5 inches lateral to the posteriormedian line.

“BL23” is located in the lumbar region at the same level as the inferiorborder of the spinous process of the second lumbar vertebra (L2), about1.5 inches lateral to the posterior median line.

“BL24” is located in the lumbar region at the same level as the inferiorborder of the spinous process of the third lumbar vertebra (L3), about1.5 inches lateral to the posterior median line.

“BL25” is located in the lumbar region at the same level as the inferiorborder of the spinous process of the fourth lumbar vertebra (L4), about1.5 inches lateral to the posterior median line.

“BL26” is located in the lumbar region at the same level as the inferiorborder of the spinous process of the fifth lumbar vertebra (L5), about1.5 inches lateral to the posterior median line.

The electrical paradigm for use as part of the present methods andsystems is one allowing for the use of low frequency, alternating lowfrequencies, alternating low and high frequency, and alternating mediumfrequencies. For paradigms requiring alternating frequencies, forexample, 15/30 Hz, means that stimulation is provided with 15 Hz forapproximately three to six seconds and then it is alternated with 30 Hzfor approximately three to six seconds. See, Xiao-Hong, C., Su-Fong, G.,Chung-Gwo, C., & JI-SHENG, H. (1994). Optimal conditions for elicitingmaximal electroacupuncture analgesia with dense-and-disperse modestimulation. American journal of acupuncture, 22(1), 47-53.

The pulse width should be approximately 0.5 ms for the recruitment ofdesired nerve fibers. The optimal pulse width might vary fromapproximately 0.2 ms to 0.7 ms as seen in electroacupuncture studiesidentified by Applicant for treatment of chronic low back pain. SeeYeung 2003 (for an example of 0.5 ms pulse width); White, P. F.,El-sayed, A. G., Ahmed, H. E., Hamza, M. A., Craig, W. F., & Vakharia,A. S. (2001), The effect of montage on the analgesic response topercutaneous neuromodulation therapy. Anesthesia & Analgesia, 92(2),483-487; Chen X., Han J S. (1992). 2/15 Hz Electrical StimulationInduced an Increase of Both Met-enkephalin-Arg-Phe and Dynorphin fromSpinal Cord in Humans, Journal of Beijing Medical University, 80 (InChinese with English translation) (hereafter, “Chen 1992”).

Unlike present state neuromodulation technologies, in particular spinalcord stimulation for treatment of pain, the methods and systemsdescribed herein use short duration of stimulation. The duration ofstimulation should be approximately 30 minutes, but may be betweenfifteen minutes and one hour, with a rate of occurrence between once andfive times weekly. The prescribed duration of stimulation follows a 2000year history of acupuncture that indicates approximately 30 minuteacupuncture sessions one time a week can provide sufficient benefit to apatient. More narrowly, every acupuncture or stimulation study on whichApplicant relies for the methods and systems described herein utilizelimited durations and a similar rate of occurrence. In fact, it isdetermined that 30 and 45 minute stimulation sessions for the treatmentof low back pain with acupuncture-like stimulation on or near the regionApplicant has identified is better than sessions of only 15 minutes ofstimulation. See, Hamza, M. A., El-sayed, A, G., White, P. F., Craig, W,F., Ahmed, H. E., Gajraj, N. M., . . . & Noe, C, E. (1999). Effect ofthe duration of electrical stimulation on the analgesic response inpatients with low back pain. Anesthesiology, 91(6), 1622 (hereafter,“Hamza 1999”).

In one study comparing the response to stimulation at or near our targetpoints utilizing different frequencies, it was determined that analternating frequency of 15 Hz and 30 Hz was most efficacious (as to theextent of the effect and its long-lasting effect) than 0 Hz, 4 Hz, or100 Hz. See, Ghoname, E. S., Craig, W. F., White, P. F., Ahmed, H. E.,Hamza, M. A., Gajraj, N. M., . . . & Noe, C. E. (1999). The effect ofstimulus frequency on the analgesic response to percutaneous electricalnerve stimulation in patients with chronic low back pain, Anesthesia andanalgesia, 88(4). 841-846 (hereafter, “Ghoname 1999”).

In three other studies performed by the same group, similar resultsutilizing an alternating frequency of 15 Hz and 30 Hz were found. See,White, P. F., Craig, W. F., Vakharia, A. S., El-sayed, A. G., Ahmed, H.E., & Hamza, M. A. (2000). Percutaneous neuromodulation therapy: doesthe location of electrical stimulation effect the acute analgesicresponse?. Anesthesia & Analgesia, 91(4), 949-954 (hereafter, “White2000”); Ghoname 1999; White, P. F., El-sayed, A. G., Ahmed, H. E.,Hamza, M. A., Craig, W. F., & Vakharia, A. S. (2001). The effect ofmontage on the analgesic response to percutaneous neuromodulationtherapy. Anesthesia & Analgesia, 92(2), 483-487 (hereafter, “White2001”); Hamza 2999.

Applicant believes that alternating frequencies of 2 Hz and 15 Hz willalso provide adequate or even optimum clinical benefit. See also,Xao-Hong, C., Su-Fong, G., Chung-Gwo, C., & JI-SHENG, H. (1994). Optimalconditions for eliciting maximal electroacupuncture analgesia withdense-and-disperse mode stimulation. American journal of acupuncture,22(1), 47-53 (hereafter, “Xao-Hong 1994”); Chen 1992; Tsui; M. L, &Cheing, G. L. (2004). The effectiveness of electroacupuncture versuselectrical heat acupuncture in the management of chronic low-back pain.Journal of Alternative & Complementary Medicine, 10(5), 803-809(hereafter, “Tsui 2004”); Carlsson, C. P., & Sjölund, B. H. (2001).Acupuncture for chronic low back pain: a randomized placebo-controlledstudy with long-term follow-up. The Clinical journal of pain, 17(4),296-305 (hereafter, “Carlsson 2002”).

There is significant work suggesting that low frequency stimulation ofthe chosen locations produces improvement in pain condition of chroniclow back pain patients. Applicant herein identifies seven studies inwhich low frequency stimulation is utilized with success. See, Yeung2003; Xin B, Zhu ZC. (2005). Observation on Therapeutic Effect ofElectro-acupuncture in the Treatment of Chronic Low Back Pain: A Reportof 30 Cases. J Acupunct Tuina (hereafter, “Xin 2005”); Strauss, A. J., &Xue, C. C. (2001). Acupuncture for chronic non-specific low back pain: Acase series study. Chinese Journal of Integrated Traditional and WesternMedicine, 7(3), 190-194 (hereafter, “Strauss 2001”); Wu, Y. C., Wang, C.M., Zhang, J. F., & Li, S. S. (2010). Clinical observation on thetreatment of relapsed lumbar disc herniation after disc surgery byacupuncture plus medication. Journal of Acupuncture and Tuina Science,8, 315-317 (hereafter, “Wu 2010”); Tsukayama, H., Yamashita, H., Amagai,H., & Tanno, Y. (2002). Randomised controlled trial comparing theeffectiveness of electroacupuncture and TENS for low back pain: apreliminary study for a pragmatic trial. Acupuncture in Medicine, 20(4),175-180 (hereafter, “Tsukayama 2002”); Ghoname, E. A., Craig, W. F.,White, P. F., Ahmed, H. E., Hamza, M. A., Henderson, B. N., . . . &Gatchel, R. J. (1999). Percutaneous electrical nerve stimulation for lowback pain: a randomized crossover study. JAMA: the journal of theAmerican Medical Association, 281(9), 818-823 (hereafter, “Ghoname1999”); and, Sakai, T. O. M. O. M. I., Tsutani, K. I. I. C. H. I. R. O.,Tsukayama, H. I. R. O. S. H. I., Nakamura, T. A. T. S. U. Z. O.,Ikeuchi, R., Kawamoto, M. A. S. A. Z. U. M. I., & Kasuya, D. A. I. C. H.I. (2001). Multi-center randomized, controlled trial of acupuncture withelectric stimulation and acupuncture-like transcutaneous electricalnerve stimulation for lumbago. J Japan Soc Acupunct Moxibustion, 51,175-84 (hereafter, “Sakai 2001”).

The intensity of stimulation should be sufficient to activate theunderlying nerves without causing discomfort. In electroacupuncture,sometimes this is identified by muscle twitching or maximal comfortlevel. Such intensity will vary depending upon the depth of insertion ofthe device and differences in anatomy. As a general guide, intensityshould vary between about 2 mA and 37 mA.

Mechanical Design

A perspective view of an exemplary embodiment of an implantableelectroacupuncture device (IEAD) 100 that may be used for the purposesdescribed herein is shown in FIG. 1. The IEAD 100 may also sometimes bereferred to as an implantable electroacupuncture stimulator (IEAS). Asseen in FIG. 1, the IEAD 100 has the appearance of a disc or coin,having a front side 106, a back side 102 (not visible in FIG. 1) and anedge side 104.

As used herein, the “front” side of the IEAD 100 is the side that ispositioned so as to face the target stimulation point (e.g., the desiredacupoint) where EA stimulation is to be applied when the IEAD isimplanted. The front side 106 may also be referred to herein as the“cathode side” 106. The “back” side 102 is the side opposite the frontside and is the side farthest away from the target stimulation pointwhen the IEAD is implanted. The “back” side 102 may also be referred toherein as the “skin” side 102. The “edge” of the IEAD is the side thatconnects or joins the front side to the back side. In FIG. 1, the IEAD100 is oriented to show the front side 106 and a portion of the edgeside 104.

Many of the features associated with the mechanical design of the IEAD100 shown in FIG. 1 are the subject of a prior U.S. Provisional patentapplication, entitled “Radial Feed-Through Packaging for An ImplantableElectroacupuncture Device”, Application No. 61/676,275, filed 26 Jul.2012, which application is incorporated here by reference.

It should be noted here that throughout this application, the terms IEAD100, IEAD housing 100, bottom case 124, can 124, or IEAD case 124, orsimilar terms, are used to describe the housing structure of the EAdevice. In some instances it may appear these terms are usedinterchangeably. However, the context should dictate what is meant bythese terms. As the drawings illustrate, particularly FIG. 7, there is abottom case 124 that comprises the “can” or “container” wherein thecomponents of the IEAD 100 are first placed and assembled duringmanufacture of the IEAD 100. When all of the components are assembledand placed within the bottom case 124, a cover plate 122 is welded tothe bottom case 124 to form the hermetically-sealed housing of the IEAD.The cathode electrode 110 is attached to the outside of the bottom case124 (which is the front side 106 of the device), and the ring anodeelectrode 120 is attached, along with its insulating layer 129, aroundthe perimeter edge 104 of the bottom case 124. Finally, a layer ofsilicone molding 125 covers the IEAD housing except for the outsidesurfaces of the anode ring electrode and the cathode electrode.

The embodiment of the IEAD 100 shown in FIG. 1 utilizes two electrodes,a cathode electrode 110 that is centrally positioned on the front side106 of the IEAD 100, and an anode electrode 120. The anode electrode 120is a ring electrode that fits around the perimeter edge 104 of the IEAD100. Not visible in FIG. 1, but which is described hereinafter inconnection with the description of FIG. 7, is a layer of insulatingmaterial 129 that electrically insulates the anode ring electrode 120from the perimeter edge 104 of the housing or case 124.

Not visible in FIG. 1, but an exemplary feature of the mechanical designof the IEAD 100, is the manner in which an electrical connection isestablished between the ring electrode 120 and electronic circuitrycarried inside of the IEAD 100. This electrical connection isestablished using a radial feed-through pin that fits within a recessformed in a segment of the edge of the case 124, as explained more fullybelow in connection with the description of FIGS. 5, 5A, 5B and 7.

In contrast to the feed-through pin that establishes electrical contactwith the anode electrode, electrical connection with the cathodeelectrode 110 is established simply by forming or attaching the cathodeelectrode 110 to the front surface 106 of the IEAD case 124. In order toprevent the entire case 124 from functioning as the cathode (which isdone to better control the electric fields established between the anodeand cathode electrodes), the entire IEAD housing is covered in a layerof silicone molding 125 (see FIG. 7), except for the outside surface ofthe anode ring electrode 120 and the cathode electrode 110.

The advantage of using a central cathode electrode and a ring anodeelectrode is described in U.S. Provisional Patent Application No.61/672,257, filed 6 Mar. 2012, entitled “Electrode Configuration forImplantable Electroacupuncture Device”, which application isincorporated herein by reference. One significant advantage of thiselectrode configuration is that it is symmetrical. That is, whenimplanted, the surgeon or other medical personnel performing the implantprocedure, need only assure that the cathode side of the IEAD 100, which(for the embodiment shown in FIGS. 1-7) is the front side of the device,faces the target tissue location that is to be stimulated. In addition,the IEAD must be implanted over the desired acupoint, or other tissuelocation, that is intended to receive the electroacupuncture (EA)stimulation. The orientation of the IEAD 100 is otherwise not important.

FIG. 1A illustrates the lumbar region of a patient and shows thelocation of some representative acupoints in that region, e.g., BL52(also sometimes referred to as acupoint Zhishi), BL23 (also sometimesreferred to as acupoint Shenshu) and GV4 (also sometimes referred to asacupoint Mingmen).

FIG. 1B also illustrates the lumbar region of a patient and shows thelocation of acupoints BL22, BL23, BL24, BL25 and BL26, any one of which,or any combination of which, may serve as a target stimulation site(s)at which an IEAD may be implanted for the treatment of chronic low backpain as taught herein.

As seen in FIG. 1A, the acupoint BL23, for example, resides in thelumbar region, at the same level as the inferior border of the spinousprocess of the second lumbar vertebra (L2), about 1.5 B-cun lateral tothe posterior median line. The measurement system using units of “B-cun”is a proportional bone (skeletal) measurement system described in theWHO Standard Acupuncture Point Locations 2008 reference book citedabove. See, in particular, pages 2, 11-13 and 20-21 of that referencebook, especially FIG. 20, on page 20, and FIG. 21, on page 21 (which WHOStandard Acupuncture Point Locations 2008 reference book is incorporatedherein by reference in its entirety). However, for an average-sizedadult, a measurement of 1.5 B-cun may be considered to be approximately1.5 inches.

FIG. 1B shows that the location of acupoints BL22, BL23, BL24, BL25 andBL26 within the lumbar region are located at approximately the samelateral position as is acupoint BL23, but at different levels relativeto the vertebra. BL22, for example, is between the first lumbar vertebra(L1) and the second lumbar vertebra (L2). BL23 is between the secondlumbar vertebra (L2) and the third lumbar vertebra (L3), BL24 is betweenthe third lumbar vertebra (L3) and the fourth lumbar vertebra (L4), BL25is between the fourth lumbar vertebra (L4) and the fifth lumbar vertebra(L5), and BL26 is just below the fifth lumbar vertebra (L5).

An implanted leadless IEAD 100 is illustrated generally in FIG. 1C,which shows a sectional view of body tissue 80 of the patient wherein arepresentative acupoint 90 has been identified that is to receiveacupuncture treatment (in this case electroacupuncture, or EA,treatment). An incision (not shown in FIG. 1B) is made into the bodytissue 80 a short distance, e.g., 10-15 mm, away from the acupoint 90.As necessary, the surgeon may form a pocket under the skin at theacupoint location. The IEAD 100, with its top side 102 being closest tothe skin, is then carefully inserted through the incision into thepocket so that the center of the IEAD is located under the acupoint 90on the skin surface. With the IEAD 100 in place, the incision is sewn orotherwise closed, leaving the IEAD 100 under the skin 80 at the locationof the acupoint 90 where electroacupuncture (EA) stimulation is desired.

In this regard, it should be noted that while the target stimulationpoint is generally identified by an “acupoint,” which is typically shownin drawings and diagrams as residing on the surface of the skin, thesurface of the skin is not the actual target stimulation point. Rather,whether such stimulation comprises manual manipulation of a needleinserted through the skin at the location on the skin surface identifiedas an “acupoint”, or whether such stimulation comprises electricalstimulation applied through an electrical field oriented to causestimulation current to flow through the tissue at a prescribed depthbelow the acupoint location on the skin surface, the actual targettissue point to be stimulated is located beneath the skin at a depth d2below or underlying the acupoint 90, where the depth d2 varies dependingon the particular acupoint location. When stimulation is applied at thetarget tissue point, such stimulation is effective at treating aselected condition of the patient, e.g., chronic low back pain, becausethere is something in the tissue at that target location, or in thevicinity of that target location, such as a nerve, a tendon, a muscle,or other type of tissue, that responds to the applied stimulation in amanner that contributes favorably to the treatment of the conditionexperienced by the patient.

FIG. 1C illustrates a sectional view of the IEAD 100 implanted so as tobe centrally located under the skin at the selected acupoint 90, andaligned with an acupoint axis line 92. Usually, for most patients, theIEAD 100 is implanted at a depth d1 of approximately 2-4 mm under theskin. The top (or “back”) side102 of the IEAD is nearest to the skin 80of the patient. The bottom (or “cathode”) side 106 of the IEAD, which isthe side on which the central cathode electrode 110 resides, is farthestfrom the skin. Because the cathode electrode 110 is centered on thebottom of the IEAD, and because the IEAD 100 is implanted so as to becentered under the location on the skin where the acupoint 90 islocated, the cathode 110 is also centered over the acupoint axis line92.

FIG. 1C further illustrates the electric field gradient lines 88 thatare created in the body tissue 86 surrounding the acupoint 90 and theacupoint axis line 92. (Note: for purposes herein, when reference ismade to providing EA stimulation at a specified acupoint, it isunderstood that the EA stimulation is provided at a depth ofapproximately d2 below the location on the skin surface where theacupoint is indicated as being located.) As seen in FIG. 1C, theelectric field gradient lines are strongest along a line that coincideswith, or is near to, the acupoint axis line 92. It is thus seen that oneof the main advantages of using a symmetrical electrode configurationthat includes a centrally located electrode surrounded by an annularelectrode is that the precise orientation of the IEAD within its implantlocation is not important. So long as one electrode is centered over thedesired target location, and the other electrode surrounds the firstelectrode (e.g., as an annular electrode), a strong electric fieldgradient is created that is aligned with the acupoint axis line. Thiscauses the EA stimulation current to flow along (or very near) theacupoint axis line 92, and will result in the desired EA stimulation inthe tissue at a depth d2 below the acupoint location indicated on theskin.

FIG. 2 shows a plan view of the “cathode” (or “front”) side 106 of theIEAD 100. As seen in FIG. 2, the cathode electrode 110 appears as acircular electrode, centered on the front side, having a diameter D1.The IEAD housing has a diameter D2 and an overall thickness or width W2.For the exemplary embodiment shown in these figures, D1 is about 4 mm,D2 is about 23 mm and W2 is a little over 2 mm (2.2 mm).

FIG. 2A shows a side view of the IEAD 100. The ring anode electrode 120,best seen in FIG. 2A, has a width W1 of about 1.0 mm, or approximately ½of the width W2 of the IEAD.

FIG. 3 shows a plan view of the “back” (or “skin”) side 102 of the IEAD100. As will be evident from subsequent figure descriptions, e.g., FIGS.5A and 5B, the back side 102 of the IEAD 100 comprises a cover plate 122that is welded in place once the bottom case 124 has all of theelectronic circuitry, and other components, placed inside of thehousing.

FIG. 3A is a sectional view of the IEAD 100 of FIG. 1 taken along theline A-A of FIG. 3. Visible in this sectional view is the feed-throughpin 130, including the distal end of the feed-through pin 130 attachedto the ring anode electrode 120. Also visible in this section view is anelectronic assembly 133 on which various electronic components aremounted, including a disc-shaped battery 132. FIG. 3A furtherillustrates how the cover plate 122 is welded, or otherwise bonded, tothe bottom case 124 in order to form the hermetically-sealed IEADhousing 100.

FIG. 4 shows a perspective view of the IEAD case 124, including thefeed-through pin 130, before the electronic components are placedtherein, and before being sealed with the a cover plate 122. The case124 is similar to a shallow “can” without a lid, having a short sidewall around its perimeter. Alternatively, the case 124 may be viewed asa short cylinder, closed at one end but open at the other. (Note, in themedical device industry the housing of an implanted device is oftenreferred to as a “can”.) The feed-through pin 130 passes through asegment of the wall of the case 124 that is at the bottom of a recess140 formed in the wall. The use of this recess 140 to hold thefeed-through pin 130 may keep the temperature-sensitive portions of thefeed-through assembly (those portions that could be damaged by excessiveheat) away from the thermal shock and residual weld stress inflictedupon the case 124 when the cover plate 122 is welded thereto.

FIG. 4A is a side view of the IEAD case 124, and shows an annular rim126 formed on both sides of the case 124. The ring anode electrode 120fits between these rims 126 once the ring electrode 120 is positionedaround the edge of the case 124. (This ring electrode 120 is, for mostconfigurations, used as an anode electrode. Hence, the ring electrode120 may sometimes be referred to herein as a ring anode electrode.However, it is noted that the ring electrode could also be employed as acathode electrode, if desired.) A silicone insulator layer 129 (see FIG.7) is placed between the backside of the ring anode electrode 120 andthe perimeter edge of the case 124 where the ring anode electrode 120 isplaced around the edge of the case 124.

FIG. 5 shows a plan view of the empty IEAD case 124 shown in theperspective view of FIG. 4. An outline of the recess cavity 140 is alsoseen in FIG. 5, as is the feed-through pin 130. A bottom edge of therecess cavity 140 is located a distance D5 radially inward from the edgeof the case 124. In one embodiment, the distance D5 is between about 2.0to 2.5 mm. The feed-through pin 130, which is just a piece of solidwire, is shown in FIG. 5 extending radially outward from the case 124above the recess cavity 140 and radially inward from the recess cavitytowards the center of the case 124. The length of this feed-through pin130 is trimmed, as needed, when a distal end (extending above therecess) is connected (welded) to the anode ring electrode 120 (passingthrough a hole in the ring electrode 120 prior to welding) and when aproximal end of the feed-through pin 130 is connected to an outputterminal of the electronic assembly 133.

FIG. 5A depicts a sectional view of the IEAD housing 124 of FIG. 5 takenalong the section line A-A of FIG. 5. FIG. 5B shows an enlarged view ordetail of the portion of FIG. 5A that is encircled with the line B.Referring to FIGS. 5A and 5B jointly, it is seen that the feed-throughpin 130 is embedded within an insulator material 136, which insulatingmaterial 136 has a diameter of D3. The feed-through pin assembly (whichpin assembly comprises the combination of the pin 130 embedded into theinsulator material 136) resides on a shoulder around an opening or holeformed in the bottom of the recess 140 having a diameter D4. For theembodiment shown in FIGS. 5A and 5B, the diameter D3 is 0.95-0.07 mm,where the −0.07 mm is a tolerance. (Thus, with the tolerance considered,the diameter D3 may range from 0.88 mm to 0.95 mm.) The diameter D4 is0.80 mm with a tolerance of −0.06 mm. (Thus, with the toleranceconsidered, the diameter D4 could range from 0.74 mm to 0.80 mm.)

The feed-through pin 130 may be made of pure platinum 99.95%. Anexemplary material for the insulator material 136 is Ruby or alumina.The IEAD case 124, and the cover 122, may be made from titanium. Thefeed-through assembly, including the feed-through pin 130, ruby/aluminainsulator 136 and the case 124 are hermetically sealed as a unit by goldbrazing. Alternatively, active metal brazing can be used. (Active metalbrazing is a form of brazing which allows metal to be joined to ceramicwithout metallization.)

The hermeticity of the sealed IEAD housing is tested using a helium leaktest, as is common in the medical device industry. The helium leak rateshould not exceed 1×10⁻⁹ STD cc/sec at 1 atm pressure. Other tests areperformed to verify the case-to-pin resistance (which should be at least15×10⁶ Ohms at 100 volts DC), the avoidance of dielectric breakdown orflashover between the pin and the case 124 at 400 volts AC RMS at 60 Hzand thermal shock.

One advantage provided by the feed-through assembly shown in FIGS. 4A,5, 5A and 5B is that the feed-through assembly made from thefeed-through pin 130, the ruby insulator 136 and the recess cavity 140(formed in the case material 124) may be fabricated and assembled beforeany other components of the IEAD 100 are placed inside of the IEAD case124. This advantage greatly facilitates the manufacture of the IEADdevice.

Additional details associated with the radial feed-through pin 130, andits use within an electronic package, such as the IEAD 100 describedherein, may be found in Applicant's co-pending patent application,“Radial Feed Through Packaging for an Implantable ElectroacupunctureDevice”, application Ser. No. 13/777,901, filed Feb. 26, 2013, whichapplication is incorporated herein by reference.

Turning next to FIG. 6, there is shown a perspective view of anelectronic assembly 133. The electronic assembly 133 includes amulti-layer printed circuit (pc) board 138, or equivalent mountingstructure, on which a battery 132 and various electronic components 134are mounted. This assembly is adapted to fit inside of the empty bottomhousing 124 of FIG. 4 and FIG. 5.

FIGS. 6A and 6B show a plan view and side view, respectively, of theelectronic assembly 133 shown in FIG. 6. The electronic components areassembled and connected together so as to perform the circuit functionsneeded for the IEAD 100 to perform its intended functions. These circuitfunctions are explained in more detail below under the sub-heading“Electrical Design”. Additional details associated with these functionsmay also be found in Applicant's earlier application, application Ser.No. 13/598,582, filed Aug. 29, 2012.

FIG. 7 shows an exploded view of the complete IEAD 100, illustrating itsmain constituent parts. As seen in FIG. 7, the IEAD 100 includes,starting on the right and going left, a cathode electrode 110, a ringanode electrode 120, an insulating layer 129, the bottom case 124 (the“can” portion of the IEAD housing, and which includes the feed-throughpin 130 which passes through an opening in the bottom of the recess 140formed as part of the case, but wherein the feed-through pin 130 isinsulated and does not make electrical contact with the metal case 124by the ruby insulator 136), the electronic assembly 133 (which includesthe battery 132 and various electronic components 134 mounted on a PCboard 138) and the cover plate 122. The cover plate 122 is welded to theedge of the bottom case 124 using laser beam welding, or some equivalentprocess, as one of the final steps in the assembly process.

Other components included in the IEAD assembly, but not necessarilyshown or identified in FIG. 7, include adhesive patches for bonding thebattery 132 to the pc board 138 of the electronic assembly 133, and forbonding the electronic assembly 133 to the inside of the bottom of thecase 124. To prevent high temperature exposure of the battery 132 duringthe assembly process, conductive epoxy is used to connect a batteryterminal to the pc board 138. Because the curing temperature ofconductive epoxy is 125° C., the following process is used: (a) firstcure the conductive epoxy of a battery terminal ribbon to the pc boardwithout the battery, (b) then glue the battery to the pc board usingroom temperature cure silicone, and (c) laser tack weld the connectingribbon to the battery.

Also not shown in FIG. 7 is the manner of connecting the proximal end ofthe feed-through pin 130 to the pc board 138, and connecting a pc boardground pad to the case 124. An exemplary method of making theseconnections is to use conductive epoxy and conductive ribbons, althoughother connection methods known in the art may also be used.

Further shown in FIG. 7 is a layer of silicon molding 125 that is usedto cover all surfaces of the entire IEAD 100 except for the anode ringelectrode 120 and the circular cathode electrode 110. An over-moldingprocess is used to accomplish this, although over-molding using siliconeLSR 70 (curing temperature of 120° C.) with an injection molding processcannot be used. Over-molding processes that may be used include: (a)molding a silicone jacket and gluing the jacket onto the case using roomtemperature cure silicone (RTV) inside of a mold, and curing at roomtemperature; (b) injecting room temperature cure silicone in a PEEK orTeflon® mold (silicone will not stick to the Teflon® or PEEK material);or (c) dip coating the IEAD 100 in room temperature cure silicone whilemasking the electrode surfaces that are not to be coated. (Note: PEEK isa well known semicrystalline thermoplastic with excellent mechanical andchemical resistance properties that are retained at high temperatures.)

When assembled, the insulating layer 129 is positioned underneath thering anode electrode 120 so that the anode electrode does not short tothe case 124. The only electrical connection made to the anode electrode120 is through the distal tip of the feed-through pin 130. Theelectrical contact with the cathode electrode 110 is made through thecase 124. However, because the entire IEAD is coated with a layer ofsilicone molding 125, except for the anode ring electrode 120 and thecircular cathode electrode 110, all stimulation current generated by theIEAD 100 must flow between the exposed surfaces of the anode andcathode.

It is noted that while the exemplary configuration described herein usesa ring anode electrode 120 placed around the edges of the IEAD housing,and a circular cathode electrode 110 placed in the center of the cathodeside of the IEAD case 124, such an arrangement could be reversed, i.e.,the ring electrode could be the cathode, and the circular electrodecould be the anode.

Moreover, the location and shape of the electrodes may be configureddifferently than is shown in the exemplary embodiment described above inconnection with FIGS. 1, and 2-7. For example, the ring anode electrode120 need not be placed around the perimeter of the device, but suchelectrode may be a flat circumferential electrode that assumes differentshapes (e.g., round or oval) that is placed on the front or back surfaceof the IEAD so as to surround the central electrode. Further, for someembodiments, the surfaces of the anode and cathode electrodes may haveconvex surfaces.

It is also noted that while an exemplary embodiment has been disclosedherein that incorporates a round, or short cylindrical-shaped housing,also referred to as a coin-shaped housing, the methods and systemsdescribed herein do not require that the case 124 (which may also bereferred to as a “container”), and its associated cover plate 122, beround. The case could just as easily be an oval-shaped,rectangular-shaped (e.g., square with smooth corners), polygonal-shaped(e.g., hexagon-, octagon-, pentagon-shaped), button-shaped (with convextop or bottom for a smoother profile) device. Any of these alternateshapes, or others, would still permit the basic principles of themethods and systems described herein to be used to provide a robust,compact, thin, case to house the electronic circuitry and power sourcedescribed herein; as well as to help protect a feed-through assemblyfrom being exposed to excessive heat during assembly, and to allow thethin device to provide the benefits described herein related to itsmanufacture, implantation and use. For example, as long as the deviceremains relatively thin, e.g., no more than about 2-3 mm, and does nothave a maximum linear dimension greater than about 25 mm, then thedevice can be readily implanted in a pocket over the tissue area wherethe selected acupuoint(s) is located. As long as there is a recess inthe wall around the perimeter of the case wherein the feed-throughassembly may be mounted, which recess effectively moves the wall or edgeof the case inwardly into the housing a safe thermal distance, as wellas a safe residual weld stress distance, from the perimeter wall where ahermetically-sealed weld occurs, the principles of the methods andsystems described herein apply.

Further, it should be noted that while the exemplary configuration ofthe IEAD described herein utilizes a central electrode on one of itssurfaces that is round, having a diameter of nominally 4 mm, suchcentral electrode need not necessarily be round. It could be ovalshaped, polygonal-shaped, or shaped otherwise, in which case its size isbest defined by its maximum width, which will generally be no greaterthan about 7 mm.

Finally, it is noted that the electrode arrangement may be modifiedsomewhat, and the desired attributes of the methods and systemsdescribed herein may still be achieved. For example, as indicatedpreviously, an exemplary electrode configuration for use with themethods and systems described herein utilizes a symmetrical electrodeconfiguration, e.g., an annular electrode of a first polarity thatsurrounds a central electrode of a second polarity. Such a symmetricalelectrode configuration makes the implantable electroacupuncture device(IEAD) relatively immune to being implanted in an improper orientationrelative to the body tissue at the selected acupoint(s) that is beingstimulated. However, an electrode configuration that is not symmetricalmay still be used and many of the therapeutic effects of the methods andsystems described herein may still be achieved. For example, twospaced-apart electrodes on a front surface of the housing, one of afirst polarity, and a second of a second polarity, could still, whenoriented properly with respect to a selected acupoint tissue location,provide some desired therapeutic results.

Applicant's earlier-filed application, application Ser. No. 13/598,582,filed Aug. 29, 2012, and its appendices, schematically illustrate somealternative electrode configurations that may be used with the methodsand systems described herein. All of these alternative electrodeconfigurations, shown, e.g., in FIG. 7A of the Applicant's earlier-filedapplication, and the accompanying text that describes these alternativeelectrode configurations, as well as in the appendices of theearlier-filed application, are incorporated herein by reference.

Note, as has already been described above, the phrase “electrode orelectrode array,” or “electrodes or electrode arrays,” may also bereferred to herein as “electrode/array” or “electrodes/arrays,”respectively. For the ease of explanation, when an electrode array isreferred to herein that comprises a plurality (two or more) ofindividual electrodes of the same polarity, the individual electrodes ofthe same polarity within the electrode array may also be referred to as“individual electrodes”, “segments” of the electrode array, “electrodesegments”, or just “segments”.

The alternate electrode configurations shown in Applicant'searlier-filed application, and its appendices, are only representativeof a few electrode configurations that may be used with the presentmethods and systems described herein. Further, it is to be noted that acentral electrode/array need not have the same number of electrodesegments as does a surrounding electrode/array. Typically, a centralelectrode/array of a first polarity will be a single electrode; whereasthe surrounding electrode/array of a second polarity may have nindividual electrode segments, where n is an integer that can vary from1, 2, 3, . . . n. Thus, for a circumferential electrode array where n=4,there are four electrode segments of the same polarity arranged incircumferential pattern around a central electrode/array. If thecircumferential electrode array with n=4 is a symmetrical electrodearray, then the four electrode segments will be spaced apart equally ina circumferential pattern around a central electrode/array. When n=1,the circumferential electrode array reduces to a single circumferentialsegment or a single annular electrode that surrounds a centralelectrode/array.

Additionally, the polarities of the electrode/arrays may be selected asneeded. That is, while a central electrode/array is typically a cathode(−), and a surrounding electrode/array is typically an anode (+), thesepolarities may be reversed.

It should be noted that the shape of the circumferentialelectrode/array, whether circular, oval, or other shape, need notnecessarily be the same shape as the IEAD housing, unless thecircumferential electrode/array is attached to a perimeter edge of theIEAD housing. The IEAD housing may be round, or it may be oval, or itmay have a polygon shape, or other shape, as needed to suit the needs ofa particular manufacturer and/or patient.

For a more thorough description of the electrode materials best suitedfor the cathode electrode 110 and the anode electrode 120, as well asthe surface area required for these electrodes, see Applicant'sco-pending patent application, “Electrode Configuration for anImplantable Electroacupuncture Device”, application Ser. No. 13/776,155,filed Feb. 25, 2013, which application is incorporated hereby byreference.

Additional electrode configurations, both symmetrical electrodeconfigurations and non-symmetrical electrode configurations, that may beused with an EA stimulation device as described herein, are illustratedin the appendices of Applicant's earlier-filed application, U.S.application Ser. No. 13/598,582, filed Aug. 29, 2012, previouslyincorporated herein by reference.

One of the advantages of the IEAD 100 shown in FIG. 1 is that it isleadless. However, this advantage can sometimes create a difficulty whenthe desired tissue stimulation point does not allow the IEAD 100 to beplaced sufficiently near the specified target stimulation point in orderto stimulate such target point with the needed intensity. To overcomethis difficulty, an alternative embodiment of the IEAD housing—shown inFIGS. 7A, 7B, 7C and 7D—uses a short lead attached to, e.g., thecathode, that allows the cathode to be placed closer to the targetstimulation site than otherwise would be possible. For treating lowerback pain, this means the alternative embodiment of the IEAD housingshown in FIG. 7A, 7B, 7C, or 7D may be used to place the cathode closerto the lumbar nerve, and dorsal roots.

Thus, shown in FIGS. 7A-7D, is an example of an alternate housingconfiguration that may be used in order to place a unipolar electrode,typically the cathode electrode, closer to the desired targetstimulation point, e.g., a specified acupoint, than is possible usingonly the IEAD 100 shown in FIG. 1.

As seen in FIGS. 7A-7D, a short monopolar lead 340, having its proximalend mechanically attached to the IEAD housing and electrically connectedto electrical circuitry within the IEAD that would normally be connectedto one of the two electrodes formed on the case of the IEAD if the IEADwere leadless, allows the positioning of the electrode not on the caseof the IEAD to be more precisely placed than might otherwise beachievable. In this alternate configuration, stimulation pulses areapplied to target tissue by energizing the two electrodes, one on thecase of the IEAD, the other at the distal end of the short lead 340.Such stimulation is referred to as “monopolar” stimulation because itoccurs between an electrode(s) having a single polarity at the end ofthe lead 340 and an electrode(s) having a single (and opposite) polarityat the case of the IEAD. A lead with a single-polarity electrode at itsdistal end may also sometimes be referred to as a “unipolar” lead.

FIG. 7A illustrates the main components of the alternative embodiment ofthe IEAD housing described above. As seen in FIG. 7A, these componentsinclude (1) a leadless IEAD device 100 of the type described previouslyin connection with FIGS. 1-7; and (2) a smooth and relatively short lead340. For purposes herein, the lead 340 comprises a conductive wire orcable placed inside of a smooth non-conductive catheter. In other wordsthe lead 340 may be thought of as a catheter lead, or a flexible,insulated, unipolar extension lead. The conductive wire or a cable,comprising several conductive wire fibers wound together, is exposedelectically to the tissue through an electrode interface at a distal end344 of the catheter lead 340. The length of the catheter lead 340 istypically no more than about 50 mm, and may be as short as 10 mm.

FIG. 7B shows a configuration wherein the conductive wire cable at theproximal end 342 of the extension lead 340 is welded, or otherwisebonded to, the surface of the housing of the IEAD 100. Once so attached,the entire surface of the IEAD housing is overmolded, painted orotherwise covered, with a layer 346 of silicon, or other suitableinsulator, so that an electrical connection can be made with thecatheter electrode only through the exposed electrode interface at thedistal end 344 of the short lead 340 conductive wire. The extensioncatheter lead 340 thus effectively relocates or transfers the positionof the catheter electrode from a surface of the IEAD housing to thedistal end 344 of the catheter lead. A suitable conductive electrodesurface, e.g., in the form of a cap, may be formed at the distal end ofthe catheter lead 344, as needed or desired using electrode interfacematerials such as platinum or platinum iridium alloy.

FIG. 7B thus shows a modified EA device 100′, having the proximal end ofan extension cable 340 attached to its housing 120, thereby effectivelyrelocating the position of the cathode electrode to the distal end 344of the catheter lead.

FIG. 7C shows a proximal end 342 of the short extension lead of FIG. 7Aattached to the perimeter edge of the IEAD housing, and includes the useof a strain gauge 345 to help better secure the proximal end of the leadto its desired attachment location on the perimeter edge. When soattached, the proximal end of the short extension lead 340 is mosteasily attached to the ring electrode 120 that is located on theperimeter edge of the modified IEAD housing 100′. As needed, this ringelectrode 120 may act as the cathode electrode, while the centralelectrode 110 (which is usually the cathode electrode) could, in thisinstance, be the anode electrode.

FIG. 7D schematically illustrates an exemplary use of the modified IEADhousing 100′ of FIG. 7B or 7C positioned so as to place the cathodeelectrode, i.e., the distal end 344 of the catheter lead 340, closer tothe lumbar nerve and dorsal roots while the IEAD housing 100′ remainssubcutaneously positioned at a desired acupoint, e.g., at acupoint BL22,BL23, BL24, BL25 or BL26. However, even though the IEAD 100′ ispositioned at the desired acupoint, the lead 340 provides an easilyremoved unipolar, smooth catheter that is routed so as to position itsdistal tip electrode 344 within a few millimeters of the lumbar nerve ordorsal root ganglion. This routing is chosen to avoid lead migration,and is accomplished using a relatively non-invasive injection method.

One way of accomplishing a non-invasive injection method is to use asplit-able insertion catheter, similar to what is shown in U.S. Pat. No.5,322,512 (used with epidural needles) or U.S. Pat. No. 4,411,654 (usedwith catheters). These two patents, U.S. Pat. No. 5,322,512 and U.S.Pat. No. 4,411,654 are incorporated herein by reference. Here, anintroducer needle with a peel-able over lumen would be inserted down tobe close to the lumbar nerve and/or dorsal root ganglion. The introducerwould then be removed and the lead 340 from the IEAD 100 would then bepassed down and through the remaining lumen. Once positioned, the sidesof the lumen hub would be pulled apart to draw the lumen out of thetissue, leaving the lead 340 in place.

It should be noted that one of the advantages of using a modified IEADhousing 100′ of the type shown in FIG. 7B, 7C or 7D is that themodification is achieved relatively simply and inexpensively startingwith a leadless IEAD housing 100 of the type shown in FIG. 1. However,for those situations where the desired target tissue to be stimulated isnot easily accessed by a leadless device, being able to add a shortunipolar lead of the type described above in connection with FIGS. 7Athrough 7C adds more flexibility in the locations that can beeffectively stimulated to treat lower back pain using an IEAD 100 or100′ as taught herein.

One possible way to create a very short extension catheter lead 340, orthe equivalent of a very short catheter lead, is to extend or “grow” theexisting catheter electrode 110 in small increments. Such processresults in a stiff, or non-flexible lead, but a lead that cannonetheless be inserted into the tissue, like the point of a thumbtack,to place the electrode closer to the desired stimulation target. Thisprocess is illustrated in the series of sketches (a), (b), (c) and (d)shown in FIG. 7E. In FIG. 7E(a), a side view of the housing of the EAdevice 110′ is shown, including a central cathode electrode 110 and anannular ring anode electrode 120. A suitable deposition process is thenused to increase the height (or thickness) of the electrode 110, asshown in FIG. 7E(b). The additional height, or thickness, of the cathodeelectrode 110 is shown in FIG. 7E as 110′. This deposition processcontinues again, as shown in FIG. 7E(c), where the additional thicknessis depicted as 110″. The process may be repeated, as needed, until thedesired extension length has been achieved, as depicted in FIG. 7E(d),where the additional thickness or length of the catheter lead 340 isshown as 110′″.

One deposition process that may be used to form the short catheter leadshown in FIG. 7E(d) is using what is commonly described and known as a3-D “printing” process. Other suitable processes may, of course, also beused. Once the desired length of the catheter lead has been achieved,all but the distal tip 344 of the lead is covered with a suitableinsulation material, such as an over-mold non-conductive material 346.

The extension or “growing” process associated with forming the catheterlead shown in FIG. 7E (a), (b), (c) and (d) is best used for very shortcatheter leads, e.g., leads having a length on the order of 5-10 mm.

It should also be noted that the use of implanted leaded devices toprovide electrical stimulation to body tissue have existed for many,many years. Thus, there are numerous other ways and designs that couldbe used to provide a leaded device useable to treat lower back painthrough electroacupuncture stimulation, as taught herein, at thespecified lumbar nerve and dorsal roots near the acupoints BL22, BL23,BL24, BL25 or BL26. The present patent application is intended to coversuch “other ways and designs” associated with a leaded device to theextent that all the other elements of the invention claimed herein,including limitations directed to electrical circuitry, batteryimpedance, stimulation regimen, stimulation location, and the like, arealso present.

Exemplary Leaded Design

An exemplary design of a leaded device useable to treat lower back painwill next be described in connection with FIGS. 17A through 22C.

FIGS. 17A, 17B, and 17C respectively show three basic leadconfigurations that may be used with an IEAD in accordance with theteachings presented herein. A first lead configuration, shown in FIG.17A, includes a flexible lead 340 permanently attached to a perimeteredge of an IEAD 100. The lead 340 has a unipolar electrode 346 locatedat its distal end. This first configuration is essentially the same asthat which is shown and was previously described in connection with FIG.7C.

A second lead configuration, shown in FIG. 17B, includes a flexible lead340 detachably connected to a connector 350 located on a perimeter edgeof an IEAD 100. The lead 340 has a conductive ring or sleeve 343 locatedat its proximal end. This proximal ring or sleeve 343 is electricallyconnected to the electrode 346 located at the distal end of the lead340. The ring or sleeve 343 is adapted to be inserted and detachablysecured (e.g., with a set screw) into the connector 350. When securedinto the connector 350, the ring or sleeve 343 makes secure electricalconnection with the radial feed through pin 130 (see FIGS. 4 and 4A), ormore precisely with a wired connection between the tip of the feedthrough pin 130 and a receiving metal sleeve 158 (not visible in FIG.17B) into which the ring or sleeve 343 resides when the proximal ring343 is inserted the connector 350, thereby electrically connecting theradial feed through pin 130 with the distal electrode 346. Thus, use ofthe connector 350 allows the lead 340 to be selectively attached, ordetached, from the IEAD 100 by selectively inserting, or removing, theproximal end of the lead 340 from the connector 350. This type ofconnection, which can be selectively attached or detached, is referredto as “detachably connecting”, and a lead which can be thus selectivelyattached and detached is referred to as a “detachable” lead.

A third lead configuration, shown in FIG. 17C, includes a short pigtaillead 348 that has a wire therein having its proximal end permanentlyattached to the IEAD 100 (or, more precisely, to the radial feed thoughpin 130 that is connected to electrical circuitry within the IEAD 100)and its distal end terminated within a connector 352. The lead 340includes a distal electrode 344 and a proximal ring 343 that areelectrically connected to each other via a wire(s) inside of the lead340. When the proximal end 343 of the lead 340 is inserted into theconnector 352, an electrical connection is established between theproximal ring 343 and the conductive wire inside of the lead 340,thereby establishing electrical connection between the circuits withinthe IEAD 100 and the distal electrode 344. A suitable connector cover353 may be used to help seal and hold closed the connection between theconnector 352 and the proximal end 343 of the lead 340.

FIG. 18A shows an IEAD 100 that has a proximal end of a detachable lead340 inserted into a connector built into a header assembly 352 mountedon a perimeter edge of the IEAD 100. The lead is relatively short,having a length that is typically no greater than about 50 mm, but insome instances could be as long as 100 mm.

FIG. 18B shows the embodiment shown in FIG. 18A, but with the detachablelead 340 being detached from the header assembly 352. As seen in FIG.18B, the header assembly includes a septum 357 through which a set screw358 may be selectively inserted, tightened or loosened. Such set screwis used to securely fasten or unfasten the proximal ring 343 of the lead340 within the header assembly 352.

FIG. 18C shows a sectional side view taken along the line 18C-18C of theIEAD shown in FIG. 18B.

FIG. 18D shows a perspective view of the electrode 346 at the distal endthe detachable lead 340 used in FIGS. 18A and 18B. As seen in FIG. 18D,the distal electrode 346 has the general shape of a duckbill. Thisduckbill shape advantageously allows the electrode to be more easilypositioned and secured at the desired stimulation sites near the lumbarnerve and dorsal roots.

FIG. 19 illustrates a cross-sectional view of the detachable lead 340used, e.g., in FIGS. 18A and 18B. The exemplary lead 340 utilizes fourconductive wires 360 a, 360 b, 360 c and 360 d. These four wires areembedded within a suitable insulative material 362, being more or lessequidistantly separated from each other. However, in operation, the fourwires are electrically connected together so they function as a singleconductor. A hole, tunnel or lumen 364 passes through almost the entirelength of the lead 340 from the proximal end up to the location wherethe distal electrode 346 is located. This lumen 364 provides a pathwaythrough which a semi-stiff stylet may be inserted, as needed, to helpposition the distal electrode 346 at its desired location.

FIGS. 20A, 20B and 20C show a sequence of views associated with mountingthe header assembly 352 to the perimeter edge of the case 124 of theIEAD 100. More particularly, FIG. 20A depicts the header assembly 352prior to mounting it on the perimeter edge of the IEAD case 124. Theheader assembly is made principally from Titanium. It has a lumen 361formed through its various elements that receive the proximal end of thelead 340. It also includes silicone insulation 363 and lumen seals 365which are over-molded on the titanium header.

FIG. 20B illustrates the location on the perimeter edge of the IEAD case124 where the header assembly 352 is mounted relative to the location ofthe radial feed-through pin 130. As shown and oriented in FIG. 20B, thefeed through pin 130 is to the left of the left end 366 of the headerassembly 352. The header assembly 352 shown in FIG. 20B also includes aBal Seal 367 and a connector block 368.

FIG. 20C shows the header assembly after being mounted on the perimeteredge of the IEAD case 124. As seen in FIG. 20C, the feedthrough pin 130is bent to connect with the header assembly 352, which (as indicated) ismade primarily from a titantium bracket 352′. The attachment is realizedby welding the header assembly onto the perimeter edge of the case 124.

FIG. 21 illustrates a silicone jacket 370 that is placed over the IEAD100 and header assembly 352 once the header assembly has been mounted(welded) to the assembled IEAD case 124.

FIGS. 22A and 22B respectively illustrate sectional views of the headerassembly mounted on the edge of the assembled IEAD when the proximal endof the detachable lead is not inserted into the header assembly (FIG.22A) and when the proximal end of the detachable lead is inserted intothe header assembly (FIG. 22B).

As seen in FIGS. 22A and 22B, details of the header assembly 352 areshown in sectional view. A Bal seal 367 includes a coiled wire 381nested within a conductive ring or grove around the inside periphery ofa hole of a doughnut-shaped conductive ring. The Bal seal 367 is furthershown, in perspective view, in FIG. 22C. The distal tip of the feedthrough wire 130 is welded, or otherwise permanently bonded to, the caseof the Bal seal 367. Thus, when the conductive proximal end 343 of adetachable lead is inserted into the header assembly, a secureelectrical connection is realized between the feed through wire 130 andthe conductive proximal end 343. The conductive proximal end 343 is, inturn, connected to the wires 360 a, 360 b, 360 c and 360 d (see FIG. 19)that pass through the body of the lead 340 to the conductive distal tip346 of the lead.

Other details associated with the header assembly 352 are also shown inFIGS. 22A and 22B. For example, a titanium set screw 355, accessible forturning through a septum 357, allows the proximal end of the lead to befirmly secured within the header assembly, once inserted therein. Thissame set screw 355, of course, may be loosened should the need arise todetach the lead from the header assembly.

FIG. 22C shows a perspective view of a Bal Seal 367 used within theheader assembly. The Bal Seal 367 includes coiled and flexible wires 381inserted into an annular inner edge or grove (not visible in FIG. 22C)of the Bal Seal 367 that provide a secure electrical connection betweenthe Bal Seal body and the conductive proximal end of a detachable lead,when inserted into the header assembly so that the proximal end passesthrough the Bal Seal coiled wires 381. A Bal Seal 367 of the type shownin FIG. 22C may be purchased commercially from several vendors.

Electrical Design

Next, with reference to FIGS. 8A-16, the electrical design and operationof the circuits employed within the IEAD 100 will be described, whetherthat IEAD is used as a leadless device (i.e., the IEAD 100 shown inFIG. 1) or a leaded device (i.e., the IEAD 100′ shown in FIGS. 7B and7C). More details associated with the design of the electrical circuitsdescribed herein may be found in Applicant's earlier application,application Ser. No. 13/598,582, filed Aug. 29, 2012. Also, additionaldetails regarding the electrical design and operation may be gleanedfrom Applicant's co-pending patent application, “Circuits and Methodsfor Using a High Impedance, Thin, Coin-cell Type Battery in anImplantable Electroacupuncture Device,” application Ser. No. 13/769,699,filed Feb. 18, 2013, which application is incorporated herein byreference.

FIG. 8A shows a functional block diagram of an IEAD 100 made inaccordance with the teachings disclosed herein. As seen in FIG. 8A, theIEAD 100 uses an implantable battery 215 having a battery voltageV_(BAT). Also included within the IEAD 100 is a Boost Converter circuit200, an Output Circuit 202 and a Control Circuit 210. The battery 115,boost converter circuit 200, output circuit 202 and control circuit 210are all housed within an hermetically sealed housing 124.

As controlled by the control circuit 210, the output circuit 202 of theIEAD 100 generates a sequence of stimulation pulses that are deliveredto electrodes E1 and E2, through feed-through terminals 206 and 207,respectively, in accordance with a prescribed stimulation regimen. Acoupling capacitor C_(C) is also employed in series with at least one ofthe feed-through terminals 206 or 207 to prevent DC (direct current)current from flowing into the patient's body tissue.

As explained more fully below in connection with the description ofFIGS. 15A and 15B, and as can also be seen from the waveform 219 shownin the lower right corner of FIG. 8A, the prescribed stimulation regimentypically comprises a continuous stream of stimulation pulses having afixed amplitude, e.g., V_(A) volts, a fixed pulse width, e.g., 0.5millisecond, and at a fixed frequency, e.g., 2 Hz, during eachstimulation session. The stimulation session, also as part of thestimulation regimen, is generated at a very low duty cycle, e.g., for 30minutes once each week. Other stimulation regimens may also be used,e.g., using a variable frequency for the stimulus pulse during astimulation session rather than a fixed frequency. Also, the rate ofoccurrence of the stimulation session may be varied from as short as,e.g., 1 day, to as long as, e.g., 14 days.

The electrodes E1 and E2 form an integral part of the housing 124. Thatis, electrode E2 may comprise a circumferential anode electrode thatsurrounds a cathode electrode E1. The cathode electrode E1, for theembodiment described here, is electrically connected to the case 124(thereby making the feed-through terminal 206 unnecessary).

In a second exemplary embodiment, particularly well-suited forimplantable electrical stimulation devices, the anode electrode E2 iselectrically connected to the case 124 (thereby making the feed-throughterminal 207 unnecessary). The cathode electrode E1 is electricallyconnected to the circumferential electrode that surrounds the anodeelectrode E2. That is, the stimulation pulses delivered to the targettissue location (i.e., to the selected acupoint) through the electrodesE1 and E2 are, relative to a zero volt ground (GND) reference, negativestimulation pulses, as shown in the waveform diagram near the lowerright hand corner of FIG. 8A.

Thus, in the embodiment described in FIG. 8A, it is seen that during astimulation pulse the electrode E2 functions as an anode, or positive(+) electrode, and the electrode E1 functions as a cathode, or negative(−) electrode.

The battery 115 provides all of the operating power needed by the EAdevice 100. The battery voltage V_(BAT) is not the optimum voltageneeded by the circuits of the EA device, including the output circuitry,in order to efficiently generate stimulation pulses of amplitude, e.g.,−V_(A) volts. The amplitude V_(A) of the stimulation pulses is typicallymany times greater than the battery voltage V_(BAT). This means that thebattery voltage must be “boosted”, or increased, in order forstimulation pulses of amplitude V_(A) to be generated. Such “boosting”is done using the boost converter circuit 200. That is, it is thefunction of the Boost Converter circuit 200 to take its input voltage,V_(BAT), and convert it to another voltage, e.g., V_(OUT), which voltageV_(OUT) is needed by the output circuit 202 in order for the IEAD 100 toperform its intended function.

The leadless IEAD 100 shown in FIG. 8A, and packaged as described abovein connection with FIGS. 1-7, advantageously provides a tinyself-contained, coin-sized stimulator that may be implanted in a patientat or near a specified acupoint in order to favorably treat a conditionor disease of a patient. Moreover, the leaded IEAD, as packaged anddescribed above in connection with FIGS. 7A-7D and/or FIGS.17A-22C,—which leaded IEAD is realized by making only modest changes tothe packaging of the leadless IEAD—also provides a tiny self-contained,coin-sized stimulator that may be implanted near a desired targetstimulation site, but wherein the actual stimulation site may beselected more precisely by positioning the distal tip of the detachablelead 340 right next to, or even touching, the target stimulation site.Regardless of whether the leaded or leadless configuration in employed,the coin-sized stimulator advantageously applies electrical stimulationpulses at very low levels and low duty cycles in accordance withspecified stimulation regimens through electrodes that form an integralpart of the housing of the stimulator. A tiny battery inside of thecoin-sized stimulator provides enough energy for the stimulator to carryout its specified stimulation regimen over a period of several years.Thus, the coin-sized stimulator, once implanted, provides anunobtrusive, needleless, long-lasting, safe, elegant and effectivemechanism for treating certain conditions and diseases that have longbeen treated by acupuncture or electroacupuncture.

A boost converter integrated circuit (IC) typically draws current fromits power source in a manner that is proportional to the differencebetween the actual output voltage V_(OUT) and a set point outputvoltage, or feedback signal. A representative boost converter circuitthat operates in this manner is shown in FIG. 8B. At boost converterstart up, when the actual output voltage is low compared to the setpoint output voltage, the current drawn from the power source can bequite large. Unfortunately, when batteries are used as power sources,they have internal voltage losses (caused by the battery's internalimpedance) that are proportional to the current drawn from them. Thiscan result in under voltage conditions when there is a large currentdemand from the boost converter at start up or at high instantaneousoutput current. Current surges and the associated under voltageconditions can lead to undesired behavior and reduced operating life ofan implanted electro-acupuncture device.

In the boost converter circuit example shown in FIG. 8A, the battery ismodeled as a voltage source with a simple series resistance. Withreference to the circuit shown in FIG. 8A, when the series resistanceR_(BAT) is small (5 Ohms or less), the boost converter input voltageV_(IN), output voltage V_(OUT) and current drawn from the battery,I_(BAT), typically look like the waveform shown in FIG. 9A, where thehorizontal axis is time, and the vertical axis on the left is voltage,and the vertical axis of the right is current.

Referring to the waveform in FIG. 9A, at boost converter startup (10ms), there is 70 mA of current drawn from the battery with only ˜70 mVof drop in the input voltage V_(IN). Similarly, the instantaneous outputcurrent demand for electro-acupuncture pulses draws up to 40 mA from thebattery with an input voltage drop of ˜40 mV.

Disadvantageously, however, a battery with higher internal impedance(e.g., 160 Ohms), cannot source more than a milliampere or so of currentwithout a significant drop in output voltage. This problem is depictedin the timing waveform diagram shown in FIG. 9B. In FIG. 9B, as in FIG.9A, the horizontal axis is time, the left vertical axis is voltage, andthe right vertical axis is current.

As seen in FIG. 9B, as a result of the higher internal batteryimpedance, the voltage at the battery terminal (V_(IN)) is pulled downfrom 2.9 V to the minimum input voltage of the boost converter (˜1.5 V)during startup and during the instantaneous output current loadassociated with electro-acupuncture stimulus pulses. The resulting dropsin output voltage V_(OUT) are not acceptable in any type of circuitexcept an uncontrolled oscillator circuit.

Also, it should be noted that although the battery used in the boostconverter circuit is modeled in FIG. 8B as a simple series resistor,battery impedance can arise from the internal design, battery electrodesurface area and different types of electrochemical reactions. All ofthese contributors to battery impedance can cause the voltage of thebattery at the battery terminals to decrease as the current drawn fromthe battery increases.

In a suitably small and thin implantable electroacupuncture device(IEAD) of the type disclosed herein, it is desired to use a higherimpedance battery in order to assure a small and thin device, keep costslow, and/or to have low self-discharge rates. The battery internalimpedance also typically increases as the battery discharges. This canlimit the service life of the device even if a new battery hasacceptably low internal impedance. Thus, it is seen that for the IEAD100 disclosed herein to reliably perform its intended function over along period of time, a circuit design is needed for the boost convertercircuit that can manage the instantaneous current drawn from V_(IN) ofthe battery. Such current management is needed to prevent the battery'sinternal impedance from causing V_(IN) to drop to unacceptably lowlevels as the boost converter circuit pumps up the output voltageV_(OUT) and when there is high instantaneous output current demand, asoccurs when EA stimulation pulses are generated.

To provide this needed current management, the IEAD 100 disclosed hereinemploys electronic circuitry as shown in FIG. 10, or equivalentsthereof. Similar to what is shown in FIG. 8B, the circuitry of FIG. 10includes a battery, a boost converter circuit 200, an output circuit230, and a control circuit 220. The control circuit 220 generates adigital control signal that is used to duty cycle the boost convertercircuit 200 ON and OFF in order to limit the instantaneous current drawnfrom the battery. That is, the digital control signal pulses the boostconverter ON for a short time, but then shuts the boost converter downbefore a significant current can be drawn from the battery. Inconjunction with such pulsing, an input capacitance C_(F) is used toreduce the ripple in the input voltage V_(IN). The capacitor C_(F)supplies the high instantaneous current for the short time that theboost converter is ON and then recharges more slowly from the batteryduring the interval that the boost converter is OFF.

In the circuitry shown in FIG. 10, it is noted that the output voltageV_(OUT) generated by the boost converter circuit 200 is set by thereference voltage V_(REF) applied to the set point or feedback terminalof the boost converter circuit 200. For the configuration shown in FIG.10, V_(REF) is proportional to the output voltage V_(OUT), as determinedby the resistor dividing network of R1 and R2.

The switches S_(P) and S_(R), shown in FIG. 10 as part of the outputcircuit 230, are also controlled by the control circuit 220. Theseswitches are selectively closed and opened to form the EA stimulationpulses applied to the load, R_(LOAD). Before a stimulus pulse occurs,switch S_(R) is closed sufficiently long for the circuit side ofcoupling capacitor C_(C) to be charged to the output voltage, V_(OUT).The tissue side of Cc is maintained at 0 volts by the cathode electrodeE2, which is maintained at ground reference. Then, for most of the timebetween stimulation pulses, both switches S_(R) and S_(P) are kept open,with a voltage approximately equal to the output voltage V_(OUT)appearing across the coupling capacitor C_(C).

At the leading edge of a stimulus pulse, the switch S_(P) is closed,which immediately causes a negative voltage −V_(OUT) to appear acrossthe load, R_(LOAD), causing the voltage at the anode E1 to also drop toapproximately −V_(OUT), thereby creating the leading edge of thestimulus pulse. This voltage starts to decay back to 0 volts ascontrolled by an RC (resistor-capacitance) time constant that is longcompared with the desired pulse width. At the trailing edge of thepulse, before the voltage at the anode E1 has decayed very much, theswitch S_(P) is open and the switch S_(R) is closed. This action causesthe voltage at the anode E1 to immediately (relatively speaking) returnto 0 volts, thereby defining the trailing edge of the pulse. With theswitch S_(R) closed, the charge on the circuit side of the couplingcapacitor C_(C) is allowed to charge back to V_(OUT) within a timeperiod controlled by a time constant set by the values of capacitorC_(C) and resistor R3. When the circuit side of the coupling capacitorC_(C) has been charged back to V_(OUT), then switch S_(R) is opened, andboth switches S_(R) and S_(P) remain open until the next stimulus pulseis to be generated. Then the process repeats each time a stimulus pulseis to be applied across the load.

Thus, it is seen that in one embodiment of the electronic circuitry usedwithin the IEAD 100, as shown in FIG. 10, a boost converter circuit 200is employed which can be shut down with a control signal. The controlsignal is ideally a digital control signal generated by a controlcircuit 220 (which may be realized using a microprocessor or equivalentcircuit). The control signal is applied to the low side (ground side) ofthe boost converter circuit 200 (identified as the “shutdown” terminalin FIG. 10). A capacitor C_(F) supplies instantaneous current for theshort ON time that the control signal enables the boost convertercircuit to operate. And, the capacitor CF is recharged from the batteryduring the relatively long OFF time when the control signal disables theboost converter circuit.

An alternate embodiment of the electronic circuitry that may be usedwithin the IEAD 100 is shown in FIG. 11. This circuit is in mostrespects the same as the circuitry shown in FIG. 10. However, in thisalternate embodiment shown in FIG. 11, the boost converter circuit 200does not have a specific shut down input control. Rather, as seen inFIG. 11, the boost converter circuit is shut down by applying a controlvoltage to the feedback input of the boost converter circuit 200 that ishigher than V_(REF). When this happens, i.e., when the control voltageapplied to the feedback input is greater than V_(REF), the boostconverter will stop switching and draws little or no current from thebattery. The value of V_(REF) is typically a low enough voltage, such asa 1.2 V band-gap voltage, that a low level digital control signal can beused to disable the boost converter circuit. To enable the boostconverter circuit, the control signal can be set to go to a highimpedance, which effectively returns the node at the V_(REF) terminal tothe voltage set by the resistor divider network formed from R1 and R2.Alternatively the control signal can be set to go to a voltage less thanV_(REF).

A low level digital control signal that performs this function ofenabling (turning ON) or disabling (turning OFF) the boost convertercircuit is depicted in FIG. 11 as being generated at the output of acontrol circuit 220. The signal line on which this control signal ispresent connects the output of the control circuit 220 with the V_(REF)node connected to the feedback input of the boost converter circuit.This control signal, as suggested by the waveform shown in FIG. 11,varies from a voltage greater than V_(REF), thereby disabling or turningOFF the boost converter circuit, to a voltage less than V_(REF), therebyenabling or turning the boost converter circuit ON.

A refinement to the alternate embodiment shown in FIG. 11 is to use thecontrol signal to drive the low side of R2 as shown in FIG. 12. That is,as shown in FIG. 12, the boost converter circuit 200 is shut down whenthe control signal is greater than V_(REF) and runs when the controlsignal is less than V_(REF). A digital control signal can be used toperform this function by switching between ground and a voltage greaterthan V_(REF). This has the additional possibility of delta-sigmamodulation control of V_(OUT) if a measurement of the actual V_(OUT) isavailable for feedback, e.g., using a signal line 222, to thecontroller.

One exemplary embodiment of the circuitry used in an implantableelectroacupuncture device (IEAD) 100 that employs a digital controlsignal as taught herein is shown in the schematic diagram shown in FIG.13A. In FIG. 13A, there are basically four integrated circuits (ICs)used as the main components. The IC U1 is a boost converter circuit, andperforms the function of the boost converter circuit 200 describedpreviously in connection with FIGS. 8B, 10, 11 and 12.

The IC U2 is a micro-controller IC and is used to perform the functionof the control circuit 220 described previously in connection with FIGS.10, 11 and 12. An exemplary IC for this purpose is a MSP430G24521micro-controller chip made by Texas Instruments. This chip includes 8 KBof Flash memory. Having some memory included with the micro-controllermay allow the parameters associated with a selected stimulation regimento be defined and stored. One of the advantages of the IEAD describedherein is that it provides a stimulation regimen that can be definedwith just 5 parameters, as taught below in connection with FIGS. 15A and15B. This allows the programming features of the micro-controller to becarried out in a simple and straightforward manner.

The micro-controller U2 primarily performs the function of generatingthe digital signal that shuts down the boost converter to prevent toomuch instantaneous current from being drawn from the battery V_(BAT).The micro-controller U2 also controls the generation of the stimuluspulses at the desired pulse width and frequency. It further keeps trackof the time periods associated with a stimulation session, i.e., when astimulation session begins and when it ends.

The micro-controller U2 also controls the amplitude of the stimuluspulse. This is done by adjusting the value of a current generated by aProgrammable Current Source U3. In one embodiment, U3 is realized with avoltage controlled current source IC. In such a voltage controlledcurrent source, the programmed current is set by a programmed voltageappearing across a fixed resistor R5, i.e., the voltage appearing at the“OUT” terminal of U3. This programmed voltage, in turn, is set by thevoltage applied to the “SET” terminal of U3. That is, the programmedcurrent source U3 sets the voltage at the “OUT” terminal to be equal tothe voltage applied to the “SET” terminal. The programmed current thatflows through the resistor R5 is then set by Ohms Law to be the voltageat the “set” terminal divided by R5. As the voltage at the “set”terminal changes, the current flowing through resistor R5 at the “OUT”terminal changes, and this current is essentially the same as thecurrent pulled through the closed switch M1, which is essentially thesame current flowing through the load R_(LOAD). Hence, whatever currentflows through resistor R5, as set by the voltage across resistor R5, isessentially the same current that flows through the load R_(LOAD). Thus,as the micro-controller U2 sets the voltage at the “set” terminal of U3,on the signal line labeled “AMPSET”, it controls what current flowsthrough the load R_(LOAD). In no event can the amplitude of the voltagepulse developed across the load R_(LOAD) exceed the voltage V_(OUT)developed by the boost converter less the voltage drops across theswitches and current source.

The switches S_(R) and S_(P) described previously in connection withFIGS. 10, 11 and 12 are realized with transistor switches M1, M2, M3,M4, M5 and M6, each of which is controlled directly or indirectly bycontrol signals generated by the micro-controller circuit U2. For theembodiment shown in FIG. 13A, these switches are controlled by twosignals, one appearing on signal line 234, labeled PULSE, and the otherappearing on signal line 236, labeled RCHG (which is an abbreviation for“recharge”). For the circuit configuration shown in FIG. 13A, the RCHGsignal on signal line 236 is always the inverse of the PULSE signalappearing on signal line 234. This type of control does not allow bothswitch M1 and switch M2 to be open or closed at the same time. Rather,switch M1 is closed when switch M2 is open, and switch M2 is closed,when switch M1 is open. When switch M1 is closed, and switch M2 is open,the stimulus pulse appears across the load, R_(LOAD), with the currentflowing through the load, R_(LOAD), being essentially equal to thecurrent flowing through resistor R5. When the switch M1 is open, andswitch M2 is closed, no stimulus pulse appears across the load, and thecoupling capacitors C5 and C6 are recharged through the closed switch M2and resistor R6 to the voltage V_(OUT) in anticipation of the nextstimulus pulse.

The circuitry shown in FIG. 13A is only exemplary of one type of circuitthat may be used to control the pulse width, amplitude, frequency, andduty cycle of stimulation pulses applied to the load, R_(LOAD). Any typeof circuit, or control, that allows stimulation pulses of a desiredmagnitude (measured in terms of pulse width, frequency and amplitude,where the amplitude may be measured in current or voltage) to be appliedthrough the electrodes to the patient at the specified acupoint at adesired duty cycle (stimulation session duration and frequency) may beused. However, for the circuitry to perform its intended function over along period of time, e.g., years, using only a small energy source,e.g., a small coin-sized battery having a high battery impedance and arelatively low capacity, the circuitry must be properly managed andcontrolled to prevent excessive current draw from the battery.

In some examples, the circuitry used in the IEAD 100, e.g., thecircuitry shown in FIGS. 10, 11, 12, 13A, or equivalents thereof, havesome means for controlling the stimulation current that flows throughthe load, R_(LOAD), which load may be characterized as the patient'stissue impedance at and around the acupoint being stimulated. Thistissue impedance, as shown in FIGS. 11 and 12, may typically vary frombetween about 300 ohms to 2000 ohms. Moreover, it not only varies fromone patient to another, but it varies over time. Hence, there is a needto control the current that flows through this variable load, R_(LOAD).One way of accomplishing this goal is to control the stimulationcurrent, as opposed to the stimulation voltage, so that the same currentwill flow through the tissue load regardless of changes that may occurin the tissue impedance over time. The use of a voltage controlledcurrent source U3, as shown in FIG. 13A, is one way to satisfy thisneed.

Still referring to FIG. 13A, a fourth IC U4 is connected to themicro-controller U2. For the embodiment shown in FIG. 13A, the IC U4 isan electromagnetic field sensor, and it allows the presence of anexternally-generated (non-implanted) electromagnetic field to be sensed.An “electromagnetic” field, for purposes of this application includesmagnetic fields, radio frequency (RF) fields, light fields, and thelike. The electromagnetic sensor may take many forms, such as anywireless sensing element, e.g., a pickup coil or RF detector, a photondetector, a magnetic field detector, and the like. When a magneticsensor is employed as the electromagnetic sensor U4, the magnetic fieldis generated using an External Control Device (ECD) 240 thatcommunicates wirelessly, e.g., through the presence or absence of amagnetic field, with the magnetic sensor U4. (A magnetic field, or othertype of field if a magnetic field is not used, is symbolicallyillustrated in FIG. 13A by the wavy line 242.) In its simplest form, theECD 240 may simply be a magnet, and modulation of the magnetic field isachieved simply by placing or removing the magnet next to or away fromthe IEAD. When other types of sensors (non-magnetic) are employed, theECD 240 generates the appropriate signal or field to be sensed by thesensor that is used.

Use of the ECD 240 provides a way for the patient, or medical personnel,to control the IEAD 100 after it has been implanted (or before it isimplanted) with some simple commands, e.g., turn the IEAD ON, turn theIEAD OFF, increase the amplitude of the stimulation pulses by oneincrement, decrease the amplitude of the stimulation pulses by oneincrement, and the like. A simple coding scheme may be used todifferentiate one command from another. For example, one coding schemeis time-based. That is, a first command is communicated by holding amagnet near the IEAD 100, and hence near the magnetic sensor U4contained within the IEAD 100, for differing lengths of time. If, forexample, a magnet is held over the IEAD for at least 2 seconds, but nomore than 7 seconds, a first command is communicated. If a magnet isheld over the IEAD for at least 11 seconds, but no more than 18 seconds,a second command is communicated, and so forth.

Another coding scheme that could be used is a sequence-based codingscheme. That is, application of 3 magnetic pulses may be used to signalone external command, if the sequence is repeated 3 times. A sequence of2 magnetic pulses, repeated twice, may be used to signal anotherexternal command. A sequence of one magnetic pulse, followed by asequence of two magnetic pulses, followed by a sequence of threemagnetic pulses, may be used to signal yet another external command.

Other simple coding schemes may also be used, such as the letters AA,RR, HO, BT, KS using international Morse code. That is, the Morse codesymbols for the letter “A” are dot dash, where a dot is a short magneticpulse, and a dash is a long magnetic pulse. Thus, to send the letter Ato the IEAD 100 using an external magnet, the user would hold the magnetover the area where the IEAD 100 is implanted for a short period oftime, e.g., one second or less, followed by holding the magnet over theIEAD for a long period of time, e.g., more than one second.

More sophisticated magnetic coding schemes may be used to communicate tothe micro-controller chip U2 the operating parameters of the IEAD 100.For example, using an electromagnet controlled by a computer, the pulsewidth, frequency, and amplitude of the EA stimulation pulses used duringeach stimulation session may be pre-set. Also, the frequency of thestimulation sessions can be pre-set. Additionally, a master reset signalcan be sent to the device in order to re-set these parameters to defaultvalues. These same operating parameters and commands may be re-sent atany time to the IEAD 100 during its useful lifetime should changes inthe parameters be desired or needed.

The current and voltage waveforms associated with the operation of theIEAD circuitry of FIG. 13A are shown in FIG. 13B. In FIG. 13B, thehorizontal axis is time, the left vertical axis is voltage, and theright vertical axis is current. The battery in this example has 160 Ohmsof internal impedance.

Referring to FIGS. 13A and 13B, during startup, the boost converter ONtime is approximately 30 microseconds applied every 7.8 milliseconds.This is sufficient to ramp the output voltage V_(OUT) up to over 10 Vwithin 2 seconds while drawing no more than about 1 mA from the batteryand inducing only 150 mV of input voltage ripple.

The electroacupuncture (EA) simulation pulses resulting from operationof the circuit of FIG. 13A have a width of 0.5 milliseconds and increasein amplitude from approximately 1 mA in the first pulse to approximately15 mA in the last pulse. The instantaneous current drawn from thebattery is less than 2 mA for the EA pulses and the drop in batteryvoltage is less than approximately 300 mV. The boost converter isenabled (turned ON) only during the instantaneous output current surgesassociated with the 0.5 milliseconds wide EA pulses.

Another exemplary embodiment of the circuitry used in an implantableelectroacupuncture device (IEAD) 100 that employs a digital controlsignal as taught herein is shown in the schematic diagram of FIG. 14.The circuit shown in FIG. 14 is, in most respects, very similar to thecircuit described previously in connection with FIG. 13A. What is new inFIG. 14 is the inclusion of a Schottky diode D4 at the output terminalLX of the boost convertor U1 and the inclusion of a fifth integratedcircuit (IC) U5 that essentially performs the same function as theswitches M1-M6 shown in FIG. 13A.

The Schottky diode D4 helps isolate the output voltage V_(OUT) generatedby the boost converter circuit U1. This is advantageous in applicationswhere the boost converter circuit U1 is selected and operated to providean output voltage V_(OUT) that is four or five times as great as thebattery voltage, V_(BAT). For example, in the embodiment for which thecircuit of FIG. 14 is designed, the output voltage V_(OUT) is designedto be nominally 15 volts using a battery that has a nominal batteryvoltage of only 3 volts. (In contrast, the embodiment shown in FIG. 13Ais designed to provide an output voltage that is nominally 10-12 volts,using a battery having a nominal output voltage of 3 volts.)

The inclusion of the fifth IC U5 in the circuit shown in FIG. 14 is, asindicated, used to perform the function of a switch. The other ICs shownin FIG. 14, U1 (boost converter), U2 (micro-controller), U3 (voltagecontrolled programmable current source) and U4 (electromagnetic sensor)are basically the same as the IC's U1, U2, U3 and U4 describedpreviously in connection with FIG. 13A.

The IC U5 shown in FIG. 14 functions as a single pole/double throw(SPDT) switch. Numerous commercially-available ICs may be used for thisfunction. For example, an ADG1419 IC, available from Analog DevicesIncorporated (ADI) may be used. In such IC U5, the terminal “D”functions as the common terminal of the switch, and the terminals “SA”and “SB” function as the selected output terminal of the switch. Theterminals “IN” and “EN” are control terminals to control the position ofthe switch. Thus, when there is a signal present on the PULSE line,which is connected to the “IN” terminal of U5, the SPDT switch U5connects the “D” terminal to the “SB” terminal, and the SPDT switch U5effectively connects the cathode electrode E1 to the programmablecurrent source U3. This connection thus causes the programmed current,set by the control voltage AMPSET applied to the SET terminal of theprogrammable current source U3, to flow through resistor R5, which inturn causes essentially the same current to flow through the load,R_(LOAD), present between the electrodes E1 and E2. When a signal is notpresent on the PULSE line, the SPDT switch U5 effectively connects thecathode electrode E1 to the resistor R6, which allows the couplingcapacitors C12 and C13 to recharge back to the voltage V_(OUT) providedby the boost converter circuit U2.

Yet another exemplary embodiment of the circuitry used in an implantableelectroacupuncture device (IEAD) 100 that employs an ON-OFF approach toduty-cycle modulate the boost converter as a tool for limiting theamount of instantaneous battery current drawn from the high impedancebattery 215 is shown in the schematic diagram of FIG. 14A. The circuitshown in FIG. 14A is, in most respects, very similar to, or the same as,the circuit described previously in connection with FIG. 14 or FIG. 13A,and that description will not be repeated here. What is new in FIG. 14Aare the addition of elements and features that address additional issuesassociated with the operation of an IEAD 100.

One feature included in the circuitry of FIG. 14A, which is describedbriefly above in connection with the description of FIG. 10, is that theboost converter circuit U1 is modulated ON and OFF using digital controlgenerated within the boost converter circuit U1 itself. In accordancewith this variation, the boost converter circuit 200 shuts itself downwhenever the battery voltage falls below a predetermined level abovethat required by the remaining circuitry. For example, in the embodimentshown in FIG. 14A, the boost converter circuit U1 is realized using aMAX8570 boost converter IC, commercially available from Maxim, orequivalents thereof. This particular boost converter IC shuts down whenthe applied voltage, V_(BAT), falls below 2.5 V. Advantageously, abattery voltage of 2.5 volts is still a high enough voltage to ensurethe microcontroller IC U2, and other circuitry associated with theoperation of the IEAD 100, remain operational.

Thus, in operation, as soon as the battery voltage drops below 2.5volts, the boost converter circuit U1 shuts down, thereby limiting theinstantaneous current drawn from the battery. When the boost converterU1 shuts down, the instantaneous battery current drawn from the batteryis immediately reduced a significant amount, thereby causing the batteryvoltage V_(BAT) to increase.

As the battery voltage V_(BAT) increases, the boost converter circuit U1remains shut down until the microcontroller U2 determines that it istime to turn the boost converter back ON. This turn ON typically occursin one of two ways: (1) just prior to the delivery of the next stimuluspulse, a turn ON signal may be applied to the Shutdown (“SD”) terminal,signal line 243, of the boost converter circuit U1; or (2) as soon asthe battery voltage, V_(BAT), has increased a sufficient amount, assensed at the feedback terminal FB of the boost converter circuit U1,the circuits within the boost converter circuit U1 are automaticallyturned back ON, allowing the output voltage V_(OUT) to build up to avoltage level needed by the switch circuit U5 and the current sourcecircuit U3 to generate an output stimulus pulse of the desired amplitudewhen the next PULSE signal is applied to the IN terminal of the switchU5 by the microcontroller U2.

Once turned ON, the boost converter remains ON until, again, the inputvoltage drops below 2.5 volts. This pattern continues, with the boostconverter being ON for a short time, and OFF for a much longer time(typically, the duty cycle associated with this ON/OFF operation of theboost converter circuit U1 is no greater than about 0.01), therebycontrolling and limiting the amount of current that is drawn from thebattery. This ON/OFF action of U1 assures that the battery voltage,V_(BAT), always remains sufficiently high to permit operation of all thecritical circuits of the IEAD 100 (principally the circuits of themicrocontroller U2), except the boost converter circuit U1.

In an exemplary implementation, the microcontroller circuit U2 used inFIG. 14A comprises an MSP43002452IRSA 16 microcontroller, commerciallyavailable from Texas Instruments, or equivalent microcontroller Thecurrent source circuit U3 comprises a LT3092 programmable current sourcecommercially available form Linear Technology, or equivalents thereof.The sensor circuit U4 comprises an AS-M15SA-R magnetic sensor,commercially available from Murata, or equivalents thereof. And, theswitch circuit U5 comprises an ADG1419BCPZ single pole double throwanalog switch commercially available from Analog Devices, or equivalentsthereof.

Another feature or enhancement provided by the circuit implementationdepicted in FIG. 14A relates to removing, or at least minimizing, someundesirable leading edge transients that are seen in the output stimuluspulses generated by the circuitry of FIG. 14A. The solution to remove ormitigate the occurrence of such leading edge transients is to insert anN-MOSFET transistor switch Q1 at the input terminal, IN, of theprogrammable current source circuit U3. This switch Q1 acts as a“cascode” stage that maintains a more constant voltage across thecurrent source U3 as the output current and/or load resistance changes.The gate (G) terminal of the switch Q1 is driven by the battery voltage,V_(BAT), which means the voltage at the source terminal (S) of switchQ1, which is connected to the IN terminal of the current source U3, islimited to roughly V_(BAT)-V_(GS), where V_(GS) is the threshold voltageacross the gate(G)-source(S) terminals of Q1.

Use of this N-MOSFET switch Q1 as depicted in FIG. 14A advantageouslyreduces the transient leading edge of the stimulus pulse because thecapacitance looking into Q1 is much less than is seen when looking intothe current source circuit U3 because of the Miller effect. That is,there is considerable loop gain in the operation of the U3 currentsource circuit to servo the current. This loop gain directly scales theinput capacitance so that there is a much larger leading edge spike onthe pulse. This in turn causes a 30 to 40 microsecond transient at theleading edge of the current pulse as the current source U3 recoverscurrent regulation.

An example of this leading edge transient is illustrated in the timingwaveform diagram of FIG. 14B. In FIG. 14B (as well as in FIGS. 14C, 14Dand 14E, which all show similar timing waveform diagrams), thehorizontal axis is time and the vertical axis is voltage, which(assuming a resistive load of 600 ohms) may readily be converted tocurrent, as has been done in these figures. The stimulus pulse begins ata trigger location near the left edge of the waveform, labeled TRIG. Asseen in FIG. 14B, immediately after the trigger point, which should markthe beginning or leading edge of the stimulus pulse, an initial spike251 occurs that has a magnitude on the order of twice the amplitude ofthe stimulus pulse. This spike 251 shoots down (as the waveform isoriented in the figures) and then shoots back up, and eventually, aftera delay of t1 microseconds, becomes the leading edge of the pulse. Thedelay t1 is about 30-40 microseconds, which means that the leading edgeof the stimulus pulse is delayed 30-40 microseconds. Having a leadingedge delay of this magnitude is not a desirable result.

Next, with the cascode stage (comprising the switch Q1) connected to theinput terminal, IN, of the current source U3, the stimulus pulse isagain illustrated. Because the cascode stage significantly reduces theinput capacitance looking into the drain (D) terminal of the switch Q1,the leading edge transient is significantly reduced, as illustrated inthe timing waveform diagram of FIG. 14C. As seen in FIG. 14C, theleading edge transient has all but disappeared, and the delay t1 betweenthe trigger point and the leading edge of the stimulus pulse isnegligible.

Another feature or enhancement provided by the circuitry of FIG. 14A isto address a delay that is seen when starting up the programmablecurrent source U3 at low pulse amplitudes, (e.g., less than about 3 mA).A typical current stimulus output for the IEAD is on the order of 15-25mA. When a much smaller amplitude current stimulus is used, e.g., 1.5-3mA, the control signal that defines this smaller amplitude pulse issignificantly less than the one used to define the more typical stimulusamplitudes of 15-25 mA. Such a small control signal lengthens the delay,t_(D), between the trigger point, TRIG, and the leading edge 253 of thestimulus pulse. FIG. 14D illustrates this long delay, t_(D), which is onthe order of 200 microseconds.

The address the problem illustrated in the waveform diagram of FIG. 14D,a Schottky diode D5 is connected in the circuit of FIG. 14A from anoutput port on the microcontroller circuit U2 to the input port, IN, ofthe current source circuit U3. In an exemplary implementation of thecircuit of FIG. 14A, this Schottky diode D5 is realized using aBAT54XV2DKR diode, commercially available from Fairchild Semiconductor.This diode is used to warm-up or “kick start” the circuit U3 when thepulse amplitude is low so that there is less of a delay, t_(D), beforecurrent is regulated at the start of the pulse. Since the cascode stageQ1 keeps the drop across U3 low, U3 can be driven directly from themicrocontroller U2 at the start of the pulse without significantlychanging the pulse characteristics (e.g., amplitude or timing) in such away that the delay, t_(D), before current is regulated at the start ofthe pulse can be reduced.

FIG. 14E illustrates the timing waveform diagram achieved using thecircuit of FIG. 14A with the diode D5 inserted so as to allow themicrocontroller U2 to directly drive, or “kick start”, the currentsource circuit U3 at the start of the pulse. As seen in FIG. 14E, thedelay, t_(D), realized with the “kick start” has been significantlyreduced from what it was without the “kick start” (as shown in FIG.14D), e.g., from about 200 microseconds to about 40 microseconds, orless. Thus, this “kick start” feature shortens the undesired delay,t_(D), by at least a factor of about 5.

An additional feature provided by the circuitry of FIG. 14A addresses aconcern regarding EMI (electromagnetic interference). EMI can occur, forexample, during electrocautery and/or external defibrillation. Shouldany of the circuit elements used within the IEAD 100, such as the analogswitch U5, have a transient voltage exceeding approximately 0.3 V appearon its pins (which transient voltage could easily occur if the IEAD issubjected to uncontrolled EMI), then the IC could be damaged. To preventsuch possible EMI damage, the output voltage pulse, appearing on thesignal line labeled V_(PULSE), is clamped to ground through the forwardbias direction of the diode D3. In contrast, in the circuits shown inFIGS. 13A and 14, there are two zenor diodes, D2 and D3, connected backto back, to limit the voltage appearing on the V_(PULSE) line tovoltages no greater than the zenor diode voltage in either direction. Asseen in FIG. 14A, diode D2 has been replaced with a short, therebyclamping the voltage that can appear on the output voltage line—thesignal line where V_(PULSE) appears—in one polarity direction to nogreater than the forward voltage drop across the diode D3.

As is evident from the waveforms depicted in FIGS. 14B, 14C, 14D and14E, the basic current stimulus waveform is not a square wave, with a“flat top”, (or, in the case of a negative current waveform, with a“flat bottom”) as depicted in most simplified waveform diagrams (see,e.g., FIG. 15A). Rather, the current stimulus waveforms shown in FIGS.14B, 14C, 14D and 14E have what the inventors refer to as a reversetrapezoidal shape. That is, the current waveforms start at a firstvalue, at the leading edge of the pulse, and gradually ramp to a second,larger, value at the trailing edge of the pulse (i.e., the currentincreases during the pulse). For a negative-going pulse, as is shown inthese figures, the ramp slopes downward, but this corresponds to theamplitude of the pulse getting larger.

This pulse shape—a reverse trapezoidal shape—for the current stimuluspulse is by design. That is, the inventors want the current to increaseduring the pulse because such shape is believed to be more selective forthe recruitment of smaller fiber diameter tissue and nerves, and thushas the potential to be more effective in achieving its intended goal ofactivating desired tissue at the target tissue location.

The reverse trapezoidal stimulus pulse shape is illustrated in moredetail in FIG. 15, as is one manner for achieving it. Shown on the rightside of FIG. 15 is a sketch of reverse trapezoidal pulse. (Note, it isreferred to as a “reverse trapezoidal” pulse because the current, orwaveform, gets larger or increases during the pulse. This is in contrastto a conventional voltage regulated pulse, which is “trapezoidal”, butin the other direction, i.e., the current decreases during the pulse.)As seen in FIG. 15, the reverse trapezoidal pulse has a duration T1, butthe magnitude (amplitude) of the current during the pulse increases froma first value at the leading edge of the pulse to a second value at thetrailing edge of the pulse. The increase in current from the leadingedge of the pulse to the trailing edge is a value A_(P). The averageamplitude of the pulse during the pulse time T1 is a value A1, which istypically measured at a time T_(M), which is about in the middle of thepulse. That is, T_(M)=½T1.

Also shown in FIG. 15, on the left side, is the circuitry that is usedto create the reverse trapezoidal waveform. This circuitry is part ofthe circuitry shown, e.g., in FIG. 14A, and includes a capacitor C1 inparallel with a large resistor R8 (270 KΩ) connected to the “set”terminal of the programmable current source U3. The “AMPSET” signal,generated by the micro-controller circuit U2 to set the amplitude A1 ofthe current stimulus pulse to be generated, is applied to the “set”terminal of U3. When enabled by the AMPSET signal, the capacitor C1starts to charge up during the pulse at a rate of approximately 10 μA(which comes from the “set” pin of U3, i.e., from the circuitry insideof U3). For C1=0.1 microfarads, this turns out to be 100 mV/ms, or 50 mVfor a pulse having a pulse duration or width (T1) of 0.5 ms. Since thepulse current is approximately equal to V_(SET)/R5, the pulse currentwill increase by 50 mV/R5. Or, where R5 is 22 ohms, this increase incurrent turns out to be 50 mV/22=2.27 mA at the end of the 0.5 ms pulse.This increase is essentially fixed regardless of the programmed pulseamplitude.

While the circuitry described above performs the intended function ofcausing the current stimulus pulse to have a reverse trapezoidal shapein a simple and straightforward manner, it should be noted that thereare other circuits and techniques that could also be used to achievethis same result. Moreover, it would be possible to directly control theshape of the V_(SET) signal during the pulse duration in order to createany desired stimulus pulse shape.

From the above description, it is seen that an implantable IEAD 100 isprovided that uses a digital control signal to duty-cycle limit theinstantaneous current drawn from the battery by a boost converter. Threedifferent exemplary configurations (FIGS. 10, 11 and 12) are taught forachieving this desired result, and three exemplary circuit designs thatmay be used to realize this result have been disclosed (FIGS. 13A, 14and 14A). One configuration (FIG. 12) teaches the additional capabilityto delta-sigma modulate the boost converter output voltage.

Delta-sigma modulation is well described in the art. Basically, it is amethod for encoding analog signals into digital signals orhigher-resolution digital signals into lower-resolution digital signals.The conversion is done using error feedback, where the differencebetween the two signals is measured and used to improve the conversion.The low-resolution signal typically changes more quickly than thehigh-resolution signal and it can be filtered to recover the highresolution signal with little or no loss of fidelity. Delta-sigmamodulation has found increasing use in modern electronic components suchas converters, frequency synthesizers, switched-mode power supplies andmotor controllers. See, e.g., Wikipedia, Delta-sigma modulation.

Use and Operation

With the implantable electroacupuncture device (IEAD) 100 in hand, theIEAD 100 may be used most effectively to treat chronic low back pain byfirst pre-setting stimulation parameters that the device will use duringa stimulation session. FIG. 15A shows a timing waveform diagramillustrating the EA stimulation parameters used by the IEAD to generateEA stimulation pulses. As seen in FIG. 15A, there are basically fourparameters associated with a stimulation session. The time T1 definesthe duration (or pulse width) of a stimulus pulse. The time T2 definesthe time between the start of one stimulus pulse and the start of thenext stimulus pulse. The time T2 thus defines the period associated withthe frequency of the stimulus pulses. The frequency of the stimulationpulses is equal to 1/T2. The ratio of T1/T2 is typically quite low,e.g., less than 0.01. The duration of a stimulation session is definedby the time period T3. The amplitude of the stimulus pulses is definedby the amplitude A1. This amplitude may be expressed in either voltageor current.

Turning next to FIG. 15B, a timing waveform diagram is shown thatillustrates the manner in which the stimulation sessions areadministered in accordance with an exemplary stimulation regimen. FIG.15B shows several stimulation sessions of duration T3, and how often thestimulation sessions occur. The stimulation regimen thus includes a timeperiod T4 which sets the time period from the start of one stimulationsession to the start of the next stimulation session. T4 thus is theperiod of the stimulation session frequency, and the stimulation sessionfrequency is equal to 1/T4.

In order to allow the applied stimulation to achieve its desired effecton the body tissue at the selected target stimulation site, the periodof the stimulation session T4 may be varied when the stimulationsessions are first applied. This can be achieved by employing a simplealgorithm within the circuitry of the EA device that changes the valueof T4 in an appropriate manner. For example, at start up, the period T4may be set to a minimum value, T4 (min). Then, as time goes on, thevalue of T4 is gradually increased until a desired value of T4, T4(final) is reached.

By way of example, if T4 (min) is 1 day, and T4 (final) is 7 days, thevalue of T4 may vary as follows once the stimulation sessions begin:T4=1 day for the duration between the first and second stimulationsessions, then 2 days for the duration between the second and thirdstimulation sessions, then 4 days for the duration between the third andfourth stimulation sessions, and then finally 7 days for the durationbetween all subsequent stimulation sessions after the fourth stimulationsession.

Rather than increasing the value of T4 from a minimum value to a maximumvalue using a simple doubling algorithm, as described in the previousparagraph, an enhancement is to use a table of session durations andintervals whereby the automatic session interval can be shorter for thefirst week or so. For example the 1^(st) 30 minute session could bedelivered after 1 day. The 2^(nd) 30 minute session could be deliveredafter 2 days. The 3^(rd) 30 minute session could be delivered after 4days. Finally, the 4^(th) 30 minute session could be delivered for allsubsequent sessions after 7 days.

If a triggered session is delivered completely, it advances the therapyschedule to the next table entry.

Another enhancement is that the initial set amplitude only takes effectif the subsequent triggered session is completely delivered. If thefirst session is aborted by a magnet application, the device reverts toa Shelf Mode. In this way, the first session is always a triggeredsession that occurs in the clinician setting.

Finally, the amplitude and place in the session table are saved innon-volatile memory when they change. This avoids a resetting of thetherapy schedule and need to reprogram the amplitude in the event of adevice reset.

An exemplary set of parameters that could be used to define astimulation regimen is as follows:

-   -   T1=0.5 milliseconds    -   T2=500 milliseconds    -   T3=30 minutes    -   T4=7 days (10,080 minutes)    -   A1=15 volts (across 1 KΩ), or 15 milliamps (mA)

For treating chronic low back pain, exemplary ranges for each of theabove parameters in accordance with one stimulation strategy are asfollows:

-   -   T1=0.1 to 2.0 milliseconds (ms)    -   T2=67 to 1000 ms (15 Hz to 1 Hz)    -   T3=20 to 60 minutes    -   T4=1,440 to 10,080 minutes (1 day to 1 week)    -   A1=1 to 15 mA

Another way for treating chronic low back pain is to toggle thesimulation frequency between a relatively low rate of stimulation, e.g.,1 to 2 Hz, and then a higher rate of stimulation, e.g., 15 to 30 Hz, orhigher (e.g., up to 100 Hz). One way in which this toggling between alow rate and a high rate may be achieved is depicted schematically inFIG. 15C.

As seen in FIG. 15C, the stimulation session occurs during a time periodT3, the same as is shown in FIG. 15A. However, unlike FIG. 15A, thestimulation session T3 is further divided into two time periods, T3 ₁and T3 ₂. During the time period T3 ₁, the frequency of stimulation islower than it is during the time period T3 ₂. While the duration of theactual stimulation pulse T1 does not typically change, the time periodbetween stimulation pulses, T2, does change. Thus, for a lower frequencyof stimulation, as occurs during time period T3 ₁, the period of thestimulation is a time T2 ₁. The time T2 ₁ is long compared the period ofstimulation, T2 ₂, that occurs during time period T3 ₂. The time periodT2 ₁, for example, may be 0.5 sec, which corresponds to a stimulationfrequency of 2 Hz; while the time period T2 ₂, on the other hand, may be50 msec, which corresponds to a stimulation frequency of 20 Hz. The timeperiod T3 ₁ may be, e.g., 15 minutes, and the time period T3 ₂ may be,e.g., 15 minutes, thus making the total time T3 of the stimulationsession 30 minutes.

Representative values of the parameters shown in FIG. 15C in accordancewith one stimulation regimen for treating lower back pain are asfollows:

-   -   T1=0.2 to 2.0 ms    -   T2 ₁=1000 to 100 ms    -   T2 ₂=400 to 10 ms    -   T3 ₁=5 to 50 minutes    -   T3 ₂=5 to 50 minutes    -   A1=1 to 18 mA

As a variation of the toggling approach shown in FIG. 15C, which uses astimulation paradigm that switches or toggles between alternatingfrequencies, e.g., between a low frequency F_(L) (e.g., 1-2 Hz) and ahigher frequency F_(H) (e.g., 15-30 Hz), the low frequency stimulationat frequency F_(L) may be provided during a stimulation session forapproximately 3 to 6 seconds and then the higher frequency stimulationat frequency F_(H) may be provided for approximately 3 to 6 seconds.This alternating of frequencies between F_(L) and F_(H) would thencontinue through the entire stimulation session (of duration T3minutes).

It should also be noted that the alternating of frequencies betweenF_(L) and F_(H) could occur during alternate stimulation sessions. Thatis, a first stimulation session could stimulate at a frequency F_(L),and the next stimulation session could stimulate at a frequency F_(H).

The toggling or alternating between two stimulation frequencies during astimulation session while treating lower back pain is beneficial becausetwo different types of opioids are released, one when stimulating at alower frequency, e.g., 1 to 2 Hz, and another when stimulating at ahigher frequency, e.g., 15 Hz to 30 Hz. Both opioids help reduce thelower back pain the patient experiences.

It is to be emphasized that the values shown above for the stimulationregimen and ranges of stimulation parameters for use within thestimulation regimen are only exemplary. Other stimulation regimens thatcould be used, and the ranges of values that could be used for each ofthese parameters, are as defined in the claims.

It is also to be emphasized that the ranges of values presented in theclaims for the parameters used with the methods and systems describedherein have been selected after many months of careful research andstudy, and are not arbitrary. For example, the ratio of T3/T4, whichsets the duty cycle, has been carefully selected to be very low, e.g.,no more than 0.05. Maintaining a low duty cycle of this magnituderepresents a significant change over what others have attempted in theimplantable stimulator art. Not only does a very low duty cycle allowthe battery itself to be small (coin cell size), which in turn allowsthe IEAD housing to be very small, which makes the IEAD ideally suitedfor being used without leads, thereby making it relatively easy toimplant the device at the desired stimulation site (e.g., acupoint), butit also limits the frequency and duration of stimulation sessions.

Limiting the frequency and duration of the stimulation sessionsrecognizes that some treatments, such as treating chronic low back pain,are best done slowly and methodically, over time, rather than quicklyand harshly using large doses of stimulation (or other treatments) aimedat forcing a rapid change in the patient's condition. Moreover, applyingtreatments slowly and methodically is more in keeping with traditionalacupuncture methods (which, as indicated previously, are based on over2500 years of experience). In addition, this slow and methodicalconditioning is consistent with the time scale for remodeling of thecentral nervous system needed to produce the sustained therapeuticeffect. Thus, the inventors have based their treatment regimens on theslow-and-methodical approach, as opposed to the immediate-and-forcedapproach adopted by many, if not most, prior art implantable electricalstimulators.

The inventors sometimes refer to their slow-and-methodical stimulationapproach as “soft” stimulation, as opposed to the “hard” stimulation ofthe prior art, which focuses on an immediate-and-forced response.

Once the stimulation regimen has been defined and the parametersassociated with it have been pre-set into the memory of themicro-controller circuit 220, the IEAD 100 needs to be implanted.Implantation is usually a relatively simple procedure, as has beenpracticed in the art

After implantation, the IEAD must be turned ON, and otherwisecontrolled, so that the desired stimulation regimen or stimulationparadigm may be carried out. In one exemplary embodiment, control of theIEAD after implantation, as well as anytime after the housing of theIEAD has been hermetically sealed, is performed as shown in the statediagram of FIG. 16. Each circle shown in FIG. 16 represents an operating“state” of the micro-controller U2 (FIG. 13A or 14). As seen in FIG. 16,the controller U2 only operates in one of six states: (1) a “SetAmplitude” state, (2) a “Shelf Mode” state, (3) a “Triggered Session”state, (4) a “Sleep” state, (5) an “OFF” state, and an (6) “AutomaticSession” state. The “Automatic Session” state is the state thatautomatically carries out the stimulation regimen using thepre-programmed parameters that define the stimulation regimen.

Shelf Mode is a low power state in which the IEAD is placed prior toshipment. After implant, commands are made through magnet application.Magnet application means an external magnet, typically a small hand-heldcylindrical magnet, is placed over the location where the IEAD has beenimplanted. With a magnet in that location, the magnetic sensor U4 sensesthe presence of the magnet and notifies the controller U2 of themagnet's presence.

From the “Shelf Mode” state, a magnet application for 10 seconds (M. 10s) puts the IEAD in the “Set Amplitude” state. While in the “SetAmplitude” state, the stimulation starts running by generating pulses atzero amplitude, incrementing every five seconds until the patientindicates that a comfortable level has been reached. At that time, themagnet is removed to set the amplitude.

If the magnet is removed and the amplitude is non-zero (M ΛA), thedevice continues into the “Triggered Session” so the patient receivesthe initial therapy. If the magnet is removed during “Set Amplitude”while the amplitude is zero (M ΛĀ), the device returns to the ShelfMode.

The Triggered Session ends and stimulation stops after the session time(T_(S)) has elapsed and the device enters the “Sleep” state. If a magnetis applied during a Triggered Session (M), the session aborts to the“OFF” state. If the magnet remains held on for 10 seconds (M. 10 s)while in the “OFF” state, the “Set Amplitude” state is entered with thestimulation level starting from zero amplitude as described.

If the magnet is removed (M) within 10 seconds while in the OFF state,the device enters the Sleep state. From the Sleep state, the deviceautomatically enters the Automatic Session state when the sessioninterval time has expired (T_(I)). The Automatic Session deliversstimulation for the session time (T_(S)) and the device returns to theSleep state. In this embodiment, the magnet has no effect once theAutomatic Session starts so that the full therapy session is delivered.

While in the Sleep state, if a magnet has not been applied in the last30 seconds (D) and a magnet is applied for a window between 20-25seconds and then removed (M. 20:25 s), a Triggered Session is started.If the magnet window is missed (i.e. magnet removed too soon or toolate), the 30 second de-bounce period (D) is started. When de-bounce isactive, no magnet must be detected for 30 seconds before a TriggeredSession can be initiated.

The session interval timer runs while the device is in Sleep state. Thesession interval timer is initialized when the device is woken up fromShelf Mode and is reset after each session is completely delivered. Thusabort of a triggered session by magnet application will not reset thetimer, the Triggered Session must be completely delivered.

The circuitry that sets the various states shown in FIG. 16 as afunction of externally-generated magnetic control commands, or otherexternally-generated command signals, is the micro-controller U2 (FIG.14), the processor U2 (FIG. 13A), or the control circuit 220 (FIGS. 10,11 and 12). Such processor-type circuits are programmable circuits thatoperate as directed by a program. The program is often referred to as“code”, or a sequence of steps that the processor circuit follows. The“code” can take many forms, and be written in many different languagesand formats, known to those of skill in the art. Representative “code”for the micro-controller U2 (FIG. 14) for controlling the states of theIEAD as shown in FIG. 16 is found in one of the appendices incorporatedby reference herein.

In the preceding description, various exemplary embodiments have beendescribed with reference to the accompanying drawings. It will, however,be evident that various modifications and changes may be made thereto,and additional embodiments may be implemented, without departing fromthe scope of the invention as set forth in the claims that follow. Forexample, certain features of one embodiment described herein may becombined with or substituted for features of another embodimentdescribed herein. The description and drawings are accordingly to beregarded in an illustrative rather than a restrictive sense.

What is claimed is:
 1. A method of treating a chronic low back paincondition in a patient, comprising: generating, by a leadlesselectroacupuncture device implanted beneath a skin surface of thepatient at an acupoint corresponding to a target tissue location withinthe patient, stimulation sessions at a duty cycle that is less than0.05, wherein the acupoint comprises at least one of acupoints BL22,BL23, BL24, BL25, and B L26, each stimulation session included in theplurality of stimulation sessions comprises a series of stimulationpulses, the duty cycle is a ratio of T3 to T4, each stimulation sessionincluded in the stimulation sessions has a duration of T3 minutes andoccurs at a rate of once every T4 minutes, and the leadlesselectroacupuncture device comprises a central electrode of a firstpolarity centrally located on a first surface of a housing of theelectroacupuncture device and an annular electrode of a second polarityand that is spaced apart from the central electrode on the housing; andapplying, by the leadless electroacupuncture device, the stimulationsessions to the target tissue location by way of the central electrodeand the annular electrode in accordance with the duty cycle.
 2. Themethod of claim 1, wherein the target tissue location comprises at leastone of a lumbar nerve of the patient and a dorsal root ganglion of thepatient.
 3. The method of claim 1, wherein T3 is at least 10 minutes andless than 60 minutes, and wherein T4 is at least 1440 minutes and lessthan or equal to seven days.
 4. The method of claim 1, furthercomprising receiving, by the electroacupuncture device from a deviceexternal to the electroacupuncture device, a control command thatconfigures the electroacupuncture device for treating the chronic lowback pain condition.
 5. The method of claim 4, wherein the receiving ofthe control command comprises detecting, with a magnetic sensor includedin the electroacupuncture device, a magnetic field generated by thedevice external to the electroacupuncture device.
 6. The method of claim1, wherein the housing is coin-sized and coin-shaped.
 7. The method ofclaim 1, wherein the annular electrode is located on the first surfaceof the housing.
 8. The method of claim 1, wherein the annular electrodecomprises a ring electrode located around a perimeter edge of thehousing.
 9. The method of claim 1, wherein: a catheter lead iselectrically connected to the central electrode, the catheter leadhaving an electrode located at a distal end of the catheter lead andthat functions as the central electrode; and the applying of thestimulation sessions to the target tissue location further comprisesapplying the stimulation sessions by way the electrode of the catheterlead.
 10. The method of claim 1, further comprising powering electroniccircuits within the electroacupuncture device with a battery having aninternal impedance of at least 5 ohms and no more than 160 ohms.
 11. Themethod of claim 1, wherein the annular electrode surrounds the centralelectrode.
 12. The method of claim 1, wherein the annular electrodeforms a complete ring that surrounds the central electrode.